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text-align: left; } .columnClass12 { text-align: left; font-size: .95em; } columnClass13 { text-align: center; font-size: .85em; } .columnClass14 { text-align: center; /*font-size: .72em;*/ } .columnClass15 { text-align: center; font-size: .85em; } .columnClass16 { text-align: center; font-size: .85em; } .columnClass17 { text-align: center; font-size: .85em; } .columnClass18 { text-align: right; font-weight: bold; } .columnClass19 { text-align: right; font-weight: bold; line-height: 2.25em; } .invisibleTxt { font-size: .5em; color: white; background-color: transparent; } .chrCnt{ display: none; } /************************************* * Validator: * *************************************/ .error { font: italic .85em "Courier New", Courier, monospace; } --> </STYLE> <TITLE>Application for 1915(c) HCBS Waiver: Draft CT.017.04.03 - Jul 01, 2018</TITLE> </HEAD> <BODY onbeforeprint="subInDivs();" onafterprint="putBackTextAreas();"> <!--<BODY onload="fillAreas();" onbeforeprint="subInDivs();" onafterprint="putBackTextAreas();">--> <SCRIPT LANGUAGE="JScript" type="text/javascript"> function subInDivs() { var collTextAreas = document.all.tags("TEXTAREA"); var oNewDiv; var sTemp; var i; for (i = 0; i < collTextAreas.length; i++) { oNewDiv = document.createElement("DIV"); /* oNewDiv.style.width = "100%";*/ oNewDiv.id = collTextAreas(i).uniqueID + "_div"; // replace all line breaks with HTML line breaks sTemp = collTextAreas(i).value.replace(/\n/gi,"<BR>"); // match 2 spaces with to non-breaking spaces sTemp = sTemp.replace(/\s\s/gi,"&nbsp;&nbsp;"); oNewDiv.innerHTML = sTemp; if (sTemp.length > 0) { collTextAreas(i).parentNode.insertBefore(oNewDiv, collTextAreas(i)); collTextAreas(i).style.display = "none"; } oNewDiv = null; } } function putBackTextAreas() { var collTextAreas = document.all.tags("TEXTAREA"); var oDivToRemove; var i; for (i = 0; i < collTextAreas.length; i++) { oDivToRemove = document.all(collTextAreas(i).uniqueID + "_div"); if (oDivToRemove != null) { oDivToRemove.removeNode(true); } collTextAreas(i).style.display = ""; } } </SCRIPT> <div id="coverPageTitle" class="printHeader" style="font-size: 24pt;"> Application for a §1915(c) Home and Community-Based Services Waiver </div> <H2 id="pageTitle">PURPOSE OF THE HCBS WAIVER PROGRAM</H2> <div class="outputTextNB paragraph"> <p class="pph"> The Medicaid Home and Community-Based Services (HCBS) waiver program is authorized in §1915(c) of the Social Security Act. The program permits a State to furnish an array of home and community-based services that assist Medicaid beneficiaries to live in the community and avoid institutionalization. The State has broad discretion to design its waiver program to address the needs of the waiver’s target population. Waiver services complement and/or supplement the services that are available to participants through the Medicaid State plan and other federal, state and local public programs as well as the supports that families and communities provide. </p> <p class="pph"> The Centers for Medicare &amp; Medicaid Services (CMS) recognizes that the design and operational features of a waiver program will vary depending on the specific needs of the target population, the resources available to the State, service delivery system structure, State goals and objectives, and other factors. A State has the latitude to design a waiver program that is cost-effective and employs a variety of service delivery approaches, including participant direction of services. </p> </div> <div id="printHeaderAmend" class="printHeader"> Request for an Amendment to a §1915(c) Home and Community-Based Services Waiver </div> <H2 id="pageTitle">1. Request Information <span id="pageNumber"></span></H2> <OL class="alpha"> <LI> <div> <span class="outputTextNB"> The <span class="bld">State</span> of <span id="svamend1_1:state" class="outputText">Connecticut</span> requests approval for an amendment to the following Medicaid home and community-based services waiver approved under authority of §1915(c) of the Social Security Act. </span> </div> </LI> <LI class="pph"> <div> <div> <label id="svamend1_1:lblprogramTitle" for="svamend1_1:programTitle" class="outputLabel"> <span id="svamend1_1:text5" class="outputText">Program Title:</span></label> </div> <span id="svamend1_1:programTitle" class="inputTextLong">Personal Care Assistance Waiver</span> </div> </LI> <LI class="pph"> <div> <label id="svamend1_1:lblwaiverNbr" for="svamend1_1:waiverNbr" class="outputLabel"> <span id="svamend1_1:lbltxtwaiverNbr" class="outputText">Waiver Number:</span></label><span id="svamend1_1:waiverNbr" class="outputText">CT.0301</span> </div> <div> <span id="svamend1_1:txtlblOrigWvrBaseNbr_ro" class="outputText">Original Base Waiver Number: CT.0301.</span> </div> </LI> <LI class="pph"> <label id="svamend1_1:lblAmendNbr" for="svamend1_1:amendNbr" class="outputLabel"> <span id="svamend1_1:lbltxtamendNbr1" class="outputText">Amendment Number:</span></label><span id="svamend1_1:amendNbr" class="outputText"></span> </LI> <LI class="pph"> <div> <label id="svamend1_1:lbleffDtProp" for="svamend1_1:effDtProp" class="outputLabel"> <span id="svamend1_1:text1" class="outputText">Proposed Effective Date:</span><span id="svamend1_1:lbltxteffDtProp_2" class="error"> (mm/dd/yy)</span></label> </div> <div></div> <input id="svamend1_1:effDtProp" type="text" name="svamend1_1:effDtProp" value="07/01/18" class="inputText" readonly="readonly" /> <div> <label id="svamend1_1:lblparEffDtAprvd" for="svamend1_1:parEffDtAprvd" class="outputLabel"> <span id="svamend1_1:lbltxtparEffDtAprvd" class="outputText">Approved Effective Date of Waiver being Amended: </span></label><span id="svamend1_1:parEffDtAprvd" class="outputText">10/01/14</span> </div> </LI> </OL> <H2 id="pageTitle">2. Purpose(s) of Amendment <span id="pageNumber"></span></H2> <div> <span class="outputText">Purpose(s) of the Amendment. </span> <label id="svamend1_2:lbl_purposeAmend" for="svamend1_2:purposeAmend" class="outputLabel"> <span id="svamend1_2:txt_lbl_purposeAmend" class="outputTextNB">Describe the purpose(s) of the amendment:</span></label> </div> <div></div> <div class="chrCntDiv"> <label id="svamend1_2:purposeAmendChrCntLbl" for="svamend1_2:purposeAmendChrCnt" class="outputLabel"> <span id="svamend1_2:purposeAmendChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svamend1_2:purposeAmendChrCnt" type="text" name="svamend1_2:purposeAmendChrCnt" class="chrCnt" size="6" /><span id="svamend1_2:purposeAmendChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svamend1_2:panel_purposeAmend"><textarea id="svamend1_2:purposeAmend" name="svamend1_2:purposeAmend" class="inputTextarea25" onkeyup="Count(this);" readonly="readonly">The purpose of the amendment is to increase the cost cap to 120% of the average Medicaid cost of nursing home effective 7/1/18 and to 125% effective 7/1/19 to account for an increase in the wages of unionized personal care assistants as a result of a new collective bargaining agreement</textarea></span> </div> <H2 id="pageTitle">3. Nature of the Amendment <span id="pageNumber"></span></H2> <OL class="alpha"> <LI> <div> <span class="outputText">Component(s) of the Approved Waiver Affected by the Amendment. </span> <span class="outputTextNB">This amendment affects the following component(s) of the approved waiver. Revisions to the affected subsection(s) of these component(s) are being submitted concurrently </span> <span class="outputTextNB em">(check each that applies):</span> </div> <TABLE border="1" cellpadding="0" cellspacing="0" class="ckboxTable" title="" > <THEAD> <tr> <th id="comp">Component of the Approved Waiver</th> <th id="sub">Subsection(s)</th> </tr> </THEAD> <TBODY> <tr> <td class="lft"> <div class="checkboxGroup"> <input id="svamend1_3:mainincl" type="checkbox" name="svamend1_3:mainincl" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svamend1_3:lbl_mainincl" for="svamend1_3:mainincl" class="outputLabel"> <span id="svamend1_3:txtlbl_mainincl" class="outputText">Waiver Application</span></label> </div> </td> <td> <input id="svamend1_3:mainSub" type="text" name="svamend1_3:mainSub" class="inputTextPct" readonly="readonly" /> </td> </tr> <tr> <td class="lft"> <div class="checkboxGroup"> <input id="svamend1_3:apdxAincl" type="checkbox" name="svamend1_3:apdxAincl" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svamend1_3:lbl_apdxAincl" for="svamend1_3:apdxAincl" class="outputLabel"> <span id="svamend1_3:txtlbl_apdxAincl" class="outputText">Appendix A – Waiver Administration and Operation</span></label> </div> </td> <td> <input id="svamend1_3:apdxAsub" type="text" name="svamend1_3:apdxAsub" class="inputTextPct" readonly="readonly" /> </td> </tr> <tr> <td class="lft"> <div class="checkboxGroup"> <input id="svamend1_3:apdxBincl" type="checkbox" name="svamend1_3:apdxBincl" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svamend1_3:lbl_apdxBincl" for="svamend1_3:apdxBincl" class="outputLabel"> <span id="svamend1_3:txtlbl_apdxBincl" class="outputText">Appendix B – Participant Access and Eligibility</span></label> </div> </td> <td> <input id="svamend1_3:apdxBsub" type="text" name="svamend1_3:apdxBsub" value="B2-a, B2-b" class="inputTextPct" readonly="readonly" /> </td> </tr> <tr> <td class="lft"> <div class="checkboxGroup"> <input id="svamend1_3:apdxCincl" type="checkbox" name="svamend1_3:apdxCincl" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svamend1_3:lbl_apdxcincl" for="svamend1_3:apdxCincl" class="outputLabel"> <span id="svamend1_3:txtlbl_apdxCincl" class="outputText">Appendix C – Participant Services</span></label> </div> </td> <td> <input id="svamend1_3:apdxCsub" type="text" name="svamend1_3:apdxCsub" class="inputTextPct" readonly="readonly" /> </td> </tr> <tr> <td class="lft"> <div class="checkboxGroup"> <input id="svamend1_3:apdxDincl" type="checkbox" name="svamend1_3:apdxDincl" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svamend1_3:lbl_apdxDincl" for="svamend1_3:apdxDincl" class="outputLabel"> <span id="svamend1_3:txtlbl_apdxDincl" class="outputText">Appendix D – Participant Centered Service Planning and Delivery</span></label> </div> </td> <td> <input id="svamend1_3:apdxDsub" type="text" name="svamend1_3:apdxDsub" class="inputTextPct" readonly="readonly" /> </td> </tr> <tr> <td class="lft"> <div class="checkboxGroup"> <input id="svamend1_3:apdxEincl" type="checkbox" name="svamend1_3:apdxEincl" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svamend1_3:lbl_apdxEincl" for="svamend1_3:apdxEincl" class="outputLabel"> <span id="svamend1_3:txtlbl_apdxEincl" class="outputText">Appendix E – Participant Direction of Services</span></label> </div> </td> <td> <input id="svamend1_3:apdxEsub" type="text" name="svamend1_3:apdxEsub" class="inputTextPct" readonly="readonly" /> </td> </tr> <tr> <td class="lft"> <div class="checkboxGroup"> <input id="svamend1_3:apdxFincl" type="checkbox" name="svamend1_3:apdxFincl" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svamend1_3:lbl_apdxFincl" for="svamend1_3:apdxFincl" class="outputLabel"> <span id="svamend1_3:txtlbl_apdxFincl" class="outputText">Appendix F – Participant Rights</span></label> </div> </td> <td> <input id="svamend1_3:apdxFsub" type="text" name="svamend1_3:apdxFsub" class="inputTextPct" readonly="readonly" /> </td> </tr> <tr> <td class="lft"> <div class="checkboxGroup"> <input id="svamend1_3:apdxGincl" type="checkbox" name="svamend1_3:apdxGincl" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svamend1_3:lbl_apdxGincl" for="svamend1_3:apdxGincl" class="outputLabel"> <span id="svamend1_3:txtlbl_apdxGincl" class="outputText">Appendix G – Participant Safeguards</span></label> </div> </td> <td> <input id="svamend1_3:apdxGsub" type="text" name="svamend1_3:apdxGsub" class="inputTextPct" readonly="readonly" /> </td> </tr> <tr> <td class="lft"> <div class="checkboxGroup"> <input id="svamend1_3:apdxHincl" type="checkbox" name="svamend1_3:apdxHincl" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svamend1_3:lbl_apdxHincl" for="svamend1_3:apdxHincl" class="outputLabel"> <span id="svamend1_3:txtlbl_apdxHincl" class="outputText">Appendix H</span></label> </div> </td> <td> <input id="svamend1_3:apdxHsub" type="text" name="svamend1_3:apdxHsub" class="inputTextPct" readonly="readonly" /> </td> </tr> <tr> <td class="lft"> <div class="checkboxGroup"> <input id="svamend1_3:apdxIincl" type="checkbox" name="svamend1_3:apdxIincl" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svamend1_3:lbl_apdxIincl" for="svamend1_3:apdxIincl" class="outputLabel"> <span id="svamend1_3:txtlbl_apdxIincl" class="outputText">Appendix I – Financial Accountability</span></label> </div> </td> <td> <input id="svamend1_3:apdxIsub" type="text" name="svamend1_3:apdxIsub" class="inputTextPct" readonly="readonly" /> </td> </tr> <tr> <td class="lft"> <div class="checkboxGroup"> <input id="svamend1_3:apdxJincl" type="checkbox" name="svamend1_3:apdxJincl" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svamend1_3:lbl_apdxJincl" for="svamend1_3:apdxJincl" class="outputLabel"> <span id="svamend1_3:txtlbl_apdxJincl" class="outputText">Appendix J – Cost-Neutrality Demonstration</span></label> </div> </td> <td> <input id="svamend1_3:apdxJsub" type="text" name="svamend1_3:apdxJsub" class="inputTextPct" readonly="readonly" /> </td> </tr> </TBODY> </TABLE> </LI> <LI> <div> <span class="outputText">Nature of the Amendment. </span> <span class="outputTextNB">Indicate the nature of the changes to the waiver that are proposed in the amendment </span> <span class="outputTextNB em">(check each that applies):</span> </div> <div class="checkboxGroup"> <input id="svamend1_3:cb1" type="checkbox" name="svamend1_3:cb1" class="selectBooleanCheckbox" disabled="disabled" /><label id="svamend1_3:lbl_cb1" for="svamend1_3:cb1" class="outputLabel"> <span id="svamend1_3:txtlbl_cb1" class="outputText">Modify target group(s)</span></label> </div> <div class="checkboxGroup"> <input id="svamend1_3:cb2" type="checkbox" name="svamend1_3:cb2" class="selectBooleanCheckbox" disabled="disabled" /><label id="svamend1_3:lbl_cb2" for="svamend1_3:cb2" class="outputLabel"> <span id="svamend1_3:txtlbl_cb2" class="outputText">Modify Medicaid eligibility</span></label> </div> <div class="checkboxGroup"> <input id="svamend1_3:cb3" type="checkbox" name="svamend1_3:cb3" class="selectBooleanCheckbox" disabled="disabled" /><label id="svamend1_3:lbl_cb3" for="svamend1_3:cb3" class="outputLabel"> <span id="svamend1_3:txtlbl_cb3" class="outputText">Add/delete services</span></label> </div> <div class="checkboxGroup"> <input id="svamend1_3:cb4" type="checkbox" name="svamend1_3:cb4" class="selectBooleanCheckbox" disabled="disabled" /><label id="svamend1_3:lbl_cb4" for="svamend1_3:cb4" class="outputLabel"> <span id="svamend1_3:txtlbl_cb4" class="outputText">Revise service specifications</span></label> </div> <div class="checkboxGroup"> <input id="svamend1_3:cb5" type="checkbox" name="svamend1_3:cb5" class="selectBooleanCheckbox" disabled="disabled" /><label id="svamend1_3:lbl_cb5" for="svamend1_3:cb5" class="outputLabel"> <span id="svamend1_3:txtlbl_cb5" class="outputText">Revise provider qualifications</span></label> </div> <div class="checkboxGroup"> <input id="svamend1_3:cb6" type="checkbox" name="svamend1_3:cb6" class="selectBooleanCheckbox" disabled="disabled" /><label id="svamend1_3:lbl_cb6" for="svamend1_3:cb6" class="outputLabel"> <span id="svamend1_3:txtlbl_cb6" class="outputText">Increase/decrease number of participants</span></label> </div> <div class="checkboxGroup"> <input id="svamend1_3:cb7" type="checkbox" name="svamend1_3:cb7" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svamend1_3:lbl_cb7" for="svamend1_3:cb7" class="outputLabel"> <span id="svamend1_3:txtlbl_cb7" class="outputText">Revise cost neutrality demonstration</span></label> </div> <div class="checkboxGroup"> <input id="svamend1_3:cb8" type="checkbox" name="svamend1_3:cb8" class="selectBooleanCheckbox" disabled="disabled" /><label id="svamend1_3:lbl_cb8" for="svamend1_3:cb8" class="outputLabel"> <span id="svamend1_3:txtlbl_cb8" class="outputText">Add participant-direction of services</span></label> </div> <div class="checkboxGroup"> <input id="svamend1_3:cb9" type="checkbox" name="svamend1_3:cb9" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svamend1_3:lbl_cb9" for="svamend1_3:cb9" class="outputLabel"> <span id="svamend1_3:txtlbl_cb9" class="outputText">Other</span></label> </div> <div class="firstIndent"> <div> <label id="svamend1_3:lblother" for="svamend1_3:amdModOthDsc" class="outputLabel"> <span id="svamend1_3:lbltxtother" class="outputTextNB">Specify:</span></label> </div> <div> </div> <div class="chrCntDiv"> <label id="svamend1_3:amdModOthDscChrCntLbl" for="svamend1_3:amdModOthDscChrCnt" class="outputLabel"> <span id="svamend1_3:amdModOthDscChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svamend1_3:amdModOthDscChrCnt" type="text" name="svamend1_3:amdModOthDscChrCnt" class="chrCnt" size="6" /><span id="svamend1_3:amdModOthDscChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svamend1_3:jspPanelwalocHostSub"><textarea id="svamend1_3:amdModOthDsc" name="svamend1_3:amdModOthDsc" class="inputTextarea" onkeyup="Count(this);" readonly="readonly">Increase individual cost cap</textarea></span> </div> </div> </LI> </OL> <div id="printHeaderNotAmend" class="printHeader"> Application for a §1915(c) Home and Community-Based Services Waiver </div> <H2 id="pageTitle">1. Request Information <span id="pageNumber">(1 of 3)</span></H2> <OL class="alpha"> <LI class="pph"> <!--a--> <div> <span class="outputTextNB"> The <span class="bld">State</span> of <span id="svgeninfo:state" class="outputText">Connecticut</span> requests approval for a Medicaid home and community-based services (HCBS) waiver under the authority of §1915(c) of the Social Security Act (the Act). </span> </div> </LI> <LI class="pph"> <!--b--> <div> <div> <label id="svgeninfo:lblprintprogramTitle" for="svgeninfo:printProgramTitle" class="outputLabel"> <span id="svgeninfo:lbltxtprintProgramTitle" class="outputText">Program Title</span></label> <span class="outputTextNB"> (<span class="em">optional - this title will be used to locate this waiver in the finder</span>):</span> </div> <div></div> <span id="svgeninfo:panel_programTitle"><textarea id="svgeninfo:printProgramTitle" name="svgeninfo:printProgramTitle" class="inputTextarea" readonly="readonly">Personal Care Assistance Waiver</textarea></span> </div> </LI> <LI class="pph"> <!--c--> <div> <label id="svgeninfo:lblrequestType" for="svgeninfo:requestType" class="outputLabel"> <span id="svgeninfo:text3" class="outputText">Type of Request: </span></label><span id="svgeninfo:requestType" class="outputText">amendment</span> </div> <div style="padding-top: .5em; padding-bottom: .5em"> <label id="svgeninfo:lblaprvlPeriod" for="svgeninfo:aprvlPeriod" class="outputLabel"> <span id="svgeninfo:lbltxtaprvlPeriod" class="outputText">Requested Approval Period:</span></label><span id="svgeninfo:txtaprvlPeriod" class="outputTextNB em">(For new waivers requesting five year approval periods, the waiver must serve individuals who are dually eligible for Medicaid and Medicare.)</span><table id="svgeninfo:aprvlPeriod" class=""> <tr> <td> <input type="radio" name="svgeninfo:aprvlPeriod" id="svgeninfo:aprvlPeriod:0" value="3" tabindex="5" disabled="disabled" /><label for="svgeninfo:aprvlPeriod:0"> 3 years</label></td> <td> <input type="radio" checked="checked" name="svgeninfo:aprvlPeriod" id="svgeninfo:aprvlPeriod:1" value="5" tabindex="5" disabled="disabled" /><label for="svgeninfo:aprvlPeriod:1"> 5 years</label></td> </tr> </table> </div> <div class="checkboxGroup" style="margin-top: .75em;"> </div> <div> <span id="svgeninfo:txtlblOrigWvrBaseNbr_ro" class="outputText">Original Base Waiver Number: CT.0301</span> </div> <div class="pph"> </div> <div class="pph"> <label id="svgeninfo:lbldraftId" for="svgeninfo:draftId" class="outputLabel"> <span id="svgeninfo:lbltxtDraftID" class="outputText">Draft ID:</span></label><span id="svgeninfo:draftId" class="outputText" style="margin-left: 48pt;">CT.017.04.03</span> </div> <div class="pph"> <div></div> </div> </LI> <LI class="pph"> <div> <label id="svgeninfo:lblddlWaiverType" for="svgeninfo:ddlWaiverType" class="outputLabel"> <span id="svgeninfo:lbltxtddlWaiverType1" class="outputText">Type of Waiver</span><span id="svgeninfo:lbltxtddlWaiverType2" class="outputTextNB em"> (select only one):</span></label> </div> <select id="svgeninfo:ddlWaiverType" name="svgeninfo:ddlWaiverType" class="selectOneMenu" size="1" disabled="disabled"> <option value="model">Model Waiver</option> <option value="regular" selected="selected">Regular Waiver</option> </select> </LI> <LI class="pph"> <div> <label id="svgeninfo:lblparEffDtProp" for="svgeninfo:parEffDtProp" class="outputLabel"> <span id="svgeninfo:lbltxtparEffDtProp" class="outputText">Proposed Effective Date of Waiver being Amended: </span></label><span id="svgeninfo:parEffDtProp" class="outputText">10/01/14</span> </div> <div> <label id="svgeninfo:lblparEffDtAprvd" for="svgeninfo:parEffDtAprvd" class="outputLabel"> <span id="svgeninfo:lbltxtparEffDtAprvd" class="outputText">Approved Effective Date of Waiver being Amended: </span></label><span id="svgeninfo:parEffDtAprvd" class="outputText">10/01/14</span> </div> </LI> </OL> <H2 id="pageTitle">1. Request Information <span id="pageNumber">(2 of 3)</span></H2> <OL class="alpha" start="6"> <LI> <div class="outputTextNB"> <strong>Level(s) of Care</strong>. This waiver is requested in order to provide home and community-based waiver services to individuals who, but for the provision of such services, would require the following level(s) of care, the costs of which would be reimbursed under the approved Medicaid State plan (<em>check each that applies</em>): </div> <div class="checkboxGroup"> <input id="svloc:locHosp" type="checkbox" name="svloc:locHosp" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svloc:lbl_locHosp" for="svloc:locHosp" class="outputLabel"> <span id="svloc:txtlbl_locHosp" class="outputText">Hospital</span></label> </div> <div class="firstIndent"> <span id="svloc:txtlbl_locHospType" class="outputTextNB">Select applicable level of care</span> <div class="checkboxGroup"> <label><input id="svloc:locHospType:0" type="radio" name="svloc:locHospType" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;Hospital as defined in 42 CFR &sect;440.10</label> </div> <!-- rendered="#{!pc_Loc.disableLocHospSub}"> --> <div class="firstIndent"> <div> <label id="svloc:lbllocHospSub" for="svloc:locHospSub" class="outputLabel"> <span id="svloc:lbltxtLocHospSub" class="outputTextNB">If applicable, specify whether the State additionally limits the waiver to subcategories of the hospital level of care:</span></label> </div> <div> </div> <div class="chrCntDiv"> <label id="svloc:locHospSubChrCntLbl" for="svloc:locHospSubChrCnt" class="outputLabel"> <span id="svloc:locHospSubChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svloc:locHospSubChrCnt" type="text" name="svloc:locHospSubChrCnt" class="chrCnt" size="6" /><span id="svloc:locHospSubChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svloc:jspPanelwalocHostSub"><textarea id="svloc:locHospSub" name="svloc:locHospSub" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="checkboxGroup"> <label><input id="svloc:locHospType:1" type="radio" name="svloc:locHospType" value="2" onclick="return callSave(this, event);" disabled="disabled" />&#160;Inpatient psychiatric facility for individuals age 21 and under as provided in42 CFR &sect;440.160</label> </div> <div class="noShow"> <label><input id="svloc:locHospType:2" type="radio" name="svloc:locHospType" checked="checked" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label> </div> </div> <div class="checkboxGroup"> <input id="svloc:locNurFac" type="checkbox" name="svloc:locNurFac" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svloc:lbl_locNurFac" for="svloc:locNurFac" class="outputLabel"> <span id="svloc:txtlbl_locNurFac" class="outputText">Nursing Facility</span></label> </div> <div class="firstIndent"> <span id="svloc:lbltxtlocNurFacType" class="outputTextNB">Select applicable level of care</span> <div class="checkboxGroup"> <label><input id="svloc:locNurFacType:0" type="radio" name="svloc:locNurFacType" checked="checked" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;Nursing Facility as defined in 42 CFR &#65533;&#65533;440.40 and 42 CFR &#65533;&#65533;440.155</label> </div> <div class="firstIndent"> <div> <label id="svloc:lblLocNurFacSub" for="svloc:locNurFacSub" class="outputLabel"> <span id="svloc:txtlblLocNurFacSub" class="outputTextNB">If applicable, specify whether the State additionally limits the waiver to subcategories of the nursing facility level of care:</span></label> </div> <div> </div> <div class="chrCntDiv"> <label id="svloc:locNurFacSubChrCntLbl" for="svloc:locNurFacSubChrCnt" class="outputLabel"> <span id="svloc:locNurFacSubChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svloc:locNurFacSubChrCnt" type="text" name="svloc:locNurFacSubChrCnt" class="chrCnt" size="6" /><span id="svloc:locNurFacSubChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svloc:panel_locNurFacSub"><textarea id="svloc:locNurFacSub" name="svloc:locNurFacSub" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="checkboxGroup"> <label><input id="svloc:locNurFacType:1" type="radio" name="svloc:locNurFacType" value="2" onclick="return callSave(this, event);" disabled="disabled" />&#160;Institution for Mental Disease for persons with mental illnesses aged 65 and older as provided in 42 CFR &sect;440.140</label> </div> <div class="noShow"> <label><input id="svloc:locNurFacType:2" type="radio" name="svloc:locNurFacType" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label> </div> </div> <div class="checkboxGroup"> <input id="svloc:locICFMR" type="checkbox" name="svloc:locICFMR" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svloc:lbl_locICFMR" for="svloc:locICFMR" class="outputLabel"> <span id="svloc:txtlbl_locICFMR" class="outputText">Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) (as defined in 42 CFR &sect;440.150)</span></label> </div> <div class="firstIndent" id="fi_locICFMR"> <div> <label id="svloc:lbl_locICFMRSub" for="svloc:locICFMRSub" class="outputLabel"> <span id="svloc:txtlbl_locICFMRSub" class="outputTextNB">If applicable, specify whether the State additionally limits the waiver to subcategories of the ICF/IID level of care:</span></label> </div> <div> </div> <div class="chrCntDiv"> <label id="svloc:locICFMRSubChrCntLbl" for="svloc:locICFMRSubChrCnt" class="outputLabel"> <span id="svloc:locICFMRSubChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svloc:locICFMRSubChrCnt" type="text" name="svloc:locICFMRSubChrCnt" class="chrCnt" size="6" /><span id="svloc:cntMaxICFMRSub" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svloc:panel_locICFMRSub"><textarea id="svloc:locICFMRSub" name="svloc:locICFMRSub" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="checkboxGroup"> </div> </LI> </OL> <H2 id="pageTitle">1. Request Information <span id="pageNumber">(3 of 3)</span></H2> <ol start="7" class="alpha"> <li> <div> <span class="outputText">Concurrent Operation with Other Programs.</span> <span class="outputTextNB">This waiver operates concurrently with another program (or programs) approved under the following authorities</span> </div> <div class="outputTextNB"> Select one: </div> <div class="checkboxGroup"><label><input id="svconcurrentOp:concOp:1" type="radio" name="svconcurrentOp:concOp" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;Not applicable</label></div> <div class="checkboxGroup"><label><input id="svconcurrentOp:concOp:0" type="radio" name="svconcurrentOp:concOp" checked="checked" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;Applicable</label></div> <div class="firstIndent"> <div class="outputTextNB"> Check the applicable authority or authorities: </div> <div class="checkboxGroup"> <input id="svconcurrentOp:conc1915a" type="checkbox" name="svconcurrentOp:conc1915a" class="selectBooleanCheckbox" disabled="disabled" /><label id="svconcurrentOp:lblconc1915a" for="svconcurrentOp:conc1915a" class="outputLabel"> <span id="svconcurrentOp:lbltxtconc1915a" class="outputText">Services furnished under the provisions of &sect;1915(a)(1)(a) of the Act and described in Appendix I</span></label> </div> <div class="checkboxGroup"> <input id="svconcurrentOp:conc1915b" type="checkbox" name="svconcurrentOp:conc1915b" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svconcurrentOp:lblconc1915b" for="svconcurrentOp:conc1915b" class="outputLabel"> <span id="svconcurrentOp:lbltxtconc1915b" class="outputText">Waiver(s) authorized under &sect;1915(b) of the Act.</span></label> </div> <!-- rendered="#{empty varFactory.conc1915b ? false : varFactory.conc1915b}"> --> <div class="firstIndent"> <div class="outputTextNB"> <label id="svconcurrentOp:lbl_conc1915bProg" for="svconcurrentOp:conc1915bProg" class="outputLabel"> <span id="svconcurrentOp:txt_lbl_conc1915bProg" class="outputTextNB">Specify the &sect;1915(b) waiver program and indicate whether a &sect;1915(b) waiver application has been submitted or previously approved:</span></label> </div> <div></div> <div class="chrCntDiv"> <label id="svconcurrentOp:conc1915bProgChrCntLbl" for="svconcurrentOp:conc1915bProgChrCnt" class="outputLabel"> <span id="svconcurrentOp:conc1915bProgChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svconcurrentOp:conc1915bProgChrCnt" type="text" name="svconcurrentOp:conc1915bProgChrCnt" class="chrCnt" size="6" /><span id="svconcurrentOp:conc1915bProgChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svconcurrentOp:panel_conc1915bProg"><textarea id="svconcurrentOp:conc1915bProg" name="svconcurrentOp:conc1915bProg" class="inputTextarea" onkeyup="Count(this);" readonly="readonly">1915b-4 submitted 3/31/15</textarea></span> </div> <div> <span id="svconcurrentOp:txt_conc1915_a" class="outputText">Specify the &sect;1915(b) authorities under which this program operates </span><span id="svconcurrentOp:txt_conc1915_b" class="outputTextNB em"> (check each that applies):</span> </div> <div class="checkboxGroup"> <input id="svconcurrentOp:conc1915b1" type="checkbox" name="svconcurrentOp:conc1915b1" class="selectBooleanCheckbox" disabled="disabled" /><label id="svconcurrentOp:lblconc1915b1" for="svconcurrentOp:conc1915b1" class="outputLabel"> <span id="svconcurrentOp:lbltxtconc1915b1" class="outputText">&sect;1915(b)(1) (mandated enrollment to managed care)</span></label> </div> <div class="checkboxGroup"> <input id="svconcurrentOp:conc1915b2" type="checkbox" name="svconcurrentOp:conc1915b2" class="selectBooleanCheckbox" disabled="disabled" /><label id="svconcurrentOp:lblconc1915b2" for="svconcurrentOp:conc1915b2" class="outputLabel"> <span id="svconcurrentOp:lbltxtconc1915b2" class="outputText">&sect;1915(b)(2) (central broker)</span></label> </div> <div class="checkboxGroup"> <input id="svconcurrentOp:conc1915b3" type="checkbox" name="svconcurrentOp:conc1915b3" class="selectBooleanCheckbox" disabled="disabled" /><label id="svconcurrentOp:lblconc1915b3" for="svconcurrentOp:conc1915b3" class="outputLabel"> <span id="svconcurrentOp:lbltxtconc1915b3" class="outputText">&sect;1915(b)(3) (employ cost savings to furnish additional services)</span></label> </div> <div class="checkboxGroup"> <input id="svconcurrentOp:conc1915b4" type="checkbox" name="svconcurrentOp:conc1915b4" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svconcurrentOp:lblconc1915b4" for="svconcurrentOp:conc1915b4" class="outputLabel"> <span id="svconcurrentOp:lbltxtconc1915b4" class="outputText">&sect;1915(b)(4) (selective contracting/limit number of providers)</span></label> </div> </div> <div class="checkboxGroup"> <input id="svconcurrentOp:conc1932a" type="checkbox" name="svconcurrentOp:conc1932a" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svconcurrentOp:lblconc1932a" for="svconcurrentOp:conc1932a" class="outputLabel"> <span id="svconcurrentOp:lbltxtconc1932a" class="outputText">A program operated under &sect;1932(a) of the Act. </span></label> </div> <!-- rendered="#{empty varFactory.conc1115 ? false : varFactory.conc1115}"> --> <div class="firstIndent"> <div class="outputTextNB"> <label id="svconcurrentOp:lbl_conc1932aProg" for="svconcurrentOp:conc1932aProg" class="outputLabel"> <span id="svconcurrentOp:txt_lbl_conc1932aProg" class="outputTextNB">Specify the nature of the State Plan benefit and indicate whether the State Plan Amendment has been submitted or previously approved:</span></label> </div> <div></div> <div class="chrCntDiv"> <label id="svconcurrentOp:conc1932aProgChrCntLbl" for="svconcurrentOp:conc1932aProgChrCnt" class="outputLabel"> <span id="svconcurrentOp:conc1932aProgChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svconcurrentOp:conc1932aProgChrCnt" type="text" name="svconcurrentOp:conc1932aProgChrCnt" class="chrCnt" size="6" /><span id="svconcurrentOp:conc1932aProgChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svconcurrentOp:panel_conc1932aProg"><textarea id="svconcurrentOp:conc1932aProg" name="svconcurrentOp:conc1932aProg" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="checkboxGroup"> <input id="svconcurrentOp:conc1915i" type="checkbox" name="svconcurrentOp:conc1915i" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svconcurrentOp:lblconc1915i" for="svconcurrentOp:conc1915i" class="outputLabel"> <span id="svconcurrentOp:lbltxtconc1915i" class="outputText">A program authorized under &sect;1915(i) of the Act. </span></label> </div> <div class="checkboxGroup"> <input id="svconcurrentOp:conc1915j" type="checkbox" name="svconcurrentOp:conc1915j" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svconcurrentOp:lblconc1915j" for="svconcurrentOp:conc1915j" class="outputLabel"> <span id="svconcurrentOp:lbltxtconc1915j" class="outputText">A program authorized under &sect;1915(j) of the Act. </span></label> </div> <div class="checkboxGroup"> <input id="svconcurrentOp:conc1115" type="checkbox" name="svconcurrentOp:conc1115" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svconcurrentOp:lblconc1115" for="svconcurrentOp:conc1115" class="outputLabel"> <span id="svconcurrentOp:lbltxtconc1115" class="outputText">A program authorized under &sect;1115 of the Act. </span></label> </div> <!-- rendered="#{empty varFactory.conc1115 ? false : varFactory.conc1115}"> --> <div class="firstIndent"> <div class="outputTextNB"> <label id="svconcurrentOp:lbl_conc1115Prog" for="svconcurrentOp:conc1115Prog" class="outputLabel"> <span id="svconcurrentOp:txt_lbl_conc1115Prog" class="outputTextNB">Specify the program:</span></label> </div> <div></div> <div class="chrCntDiv"> <label id="svconcurrentOp:conc1115ProgChrCntLbl" for="svconcurrentOp:conc1115ProgChrCnt" class="outputLabel"> <span id="svconcurrentOp:conc1115ProgChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svconcurrentOp:conc1115ProgChrCnt" type="text" name="svconcurrentOp:conc1115ProgChrCnt" class="chrCnt" size="6" /><span id="svconcurrentOp:conc1115ProgChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svconcurrentOp:panel_conc1115Prog"><textarea id="svconcurrentOp:conc1115Prog" name="svconcurrentOp:conc1115Prog" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="checkboxGroup noShow"> <input id="svconcurrentOp:concNot" type="checkbox" name="svconcurrentOp:concNot" class="selectBooleanCheckbox" disabled="disabled" /><label id="svconcurrentOp:label7" for="svconcurrentOp:concNot" class="outputLabel"> <span id="svconcurrentOp:lblconcNot" class="outputText">Not applicable</span></label> </div> </div> <div Class="noShow"><label><input id="svconcurrentOp:concOp:2" type="radio" name="svconcurrentOp:concOp" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </li> <li style="padding-top:1em;"> <div> <span class="outputText">Dual Eligiblity for Medicaid and Medicare.</span> </div> <div class="outputTextNB">Check if applicable:</div> <input id="svconcurrentOp:concMedicaidMedicare" type="checkbox" name="svconcurrentOp:concMedicaidMedicare" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svconcurrentOp:lblconcMedicaidMedicare" for="svconcurrentOp:concMedicaidMedicare" class="outputLabel"> <span id="svconcurrentOp:lbltxtconcMedicaidMedicare" class="outputText">This waiver provides services for individuals who are eligible for both Medicare and Medicaid.</span></label> </li> </ol> <H2 id="pageTitle">2. Brief Waiver Description</H2> <div> <span class="outputText">Brief Waiver Description. </span> <label id="svBriefDescription:lbl_programDesc" for="svBriefDescription:programDesc" class="outputLabel"> <span id="svBriefDescription:txt_lbl_programDesc1" class="outputTextNB em">In one page or less</span><span id="svBriefDescription:txt_lbl_programDesc2" class="outputTextNB">, briefly describe the purpose of the waiver, including its goals, objectives, organizational structure (e.g., the roles of state, local and other entities), and service delivery methods.</span></label> </div> <div></div> <div class="chrCntDiv"> <label id="svBriefDescription:programDescChrCntLbl" for="svBriefDescription:programDescChrCnt" class="outputLabel"> <span id="svBriefDescription:programDescChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svBriefDescription:programDescChrCnt" type="text" name="svBriefDescription:programDescChrCnt" class="chrCnt" size="6" /><span id="svBriefDescription:programDescChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svBriefDescription:panel_programDesc"><textarea id="svBriefDescription:programDesc" name="svBriefDescription:programDesc" class="inputTextareaLong" onkeyup="Count(this);" readonly="readonly">Goals and Objectives: The Department of Social Services operates the Personal Care Assistance Waiver Program that assists eligible disabled adults by providing services to wrap around the newly created 1915k state plan option. The purpose of this Medicaid Waiver Program is to provide adults who have permanent, severe, and chronic physical disabilities, with access to both waiver and state plan services to help with self care activities enabling them to reside in the community rather than an institution. The goal of the PCA Waiver is to provide an alternative to institutionalization via a flexible, cost-effective program not based on the medical model, designed to give consumer's control over their lives and to achieve greater independence in a community setting. Organizational Structure: The Department of Social Services (DSS), as the state Medicaid Agency pursuant to Connecticut General Statutes (CGS) 17b-1, directly administers the PCA Waiver according to CGS 17b-605. This is a self directed waiver and DSS assures that all individuals receiving waiver services meet the categorically and medically needy eligibility and income/asset requirements. DSS is responsible for calculating the consumer's share of liability that can be applied to the cost of waiver services. DSS also informs individuals determined eligible to receive waiver services of their due process rights and gives them the choice of institutional or home and community-based services. The Department's HCBS Unit will administer the waiver, accept applications, perform the initial level of care determination and refer the client to a contracted case management provider for the initial evaluation, confirmation of the level of care and development of the service plan. DSS is responsible for determining both financial and functional eligibility for the waiver. The case management providers are required to do annual face-to-face evaluations. DSS contracts with the fiscal agent to conduct training to the waiver participant on employment laws and guidelines. The fiscal agent also engages in fiscal monitoring, claims processing and the payment of the Independent support Broker provider if it in an individual and not an agency based provider. Quarterly reports, at a minimum, are submitted to the Department to facilitate State oversight of the waiver program. In addition, routine quality assurance activities through staff meetings, training, case conferences, consumer record maintenance, and staff supervision are components of the Department's oversight of the PCA waiver program.</textarea></span> </div> <H2 id="pageTitle">3. Components of the Waiver Request</H2> <p class="outputTextNB"> <strong>The waiver application consists of the following components.</strong> <em>Note: <u>Item 3-E must be completed</u>.</em> </p> <OL class="alpha"> <LI> <p class="outputTextNB"><strong>Waiver Administration and Operation.</strong> <strong>Appendix A</strong> specifies the administrative and operational structure of this waiver.</p> </LI> <LI> <p class="outputTextNB"><strong>Participant Access and Eligibility.</strong> <strong>Appendix B</strong> specifies the target group(s) of individuals who are served in this waiver, the number of participants that the State expects to serve during each year that the waiver is in effect, applicable Medicaid eligibility and post-eligibility (if applicable) requirements, and procedures for the evaluation and reevaluation of level of care.</p> </LI> <LI> <p class="outputTextNB"><strong>Participant Services.</strong> <strong>Appendix C</strong> specifies the home and community-based waiver services that are furnished through the waiver, including applicable limitations on such services.</p> </LI> <LI> <p class="outputTextNB"><strong>Participant-Centered Service Planning and Delivery.</strong> <strong>Appendix D</strong> specifies the procedures and methods that the State uses to develop, implement and monitor the participant-centered service plan (of care).</p> </LI> <LI> <div><span class="outputText">Participant-Direction of Services. </span> <span class="outputTextNB"> When the State provides for participant direction of services, <strong>Appendix E</strong> specifies the participant direction opportunities that are offered in the waiver and the supports that are available to participants who direct their services. (<em>Select one</em>): </span> </div> <div class="aprvdSec"> <div class="checkboxGroup"><label><input id="svcomponents:particDirSvc:0" type="radio" name="svcomponents:particDirSvc" checked="checked" value="0" disabled="disabled" />&#160;Yes. This waiver provides participant direction opportunities.</label> <span class="outputTextNB em">Appendix E is required.</span></div> <div class="checkboxGroup"><label><input id="svcomponents:particDirSvc:1" type="radio" name="svcomponents:particDirSvc" value="1" disabled="disabled" />&#160;No. This waiver does not provide participant direction opportunities.</label> <span class="outputTextNB em">Appendix E is not required.</span></div> <div class="noShow"><label><input id="svcomponents:particDirSvc:2" type="radio" name="svcomponents:particDirSvc" value="99" disabled="disabled" />&#160;not selected</label></div> </div> </LI> <LI> <p class="outputTextNB"><strong>Participant Rights.</strong> <strong>Appendix F</strong> specifies how the State informs participants of their Medicaid Fair Hearing rights and other procedures to address participant grievances and complaints.</p> </LI> <LI> <p class="outputTextNB"><strong>Participant Safeguards.</strong> <strong>Appendix G</strong> describes the safeguards that the State has established to assure the health and welfare of waiver participants in specified areas.</p> </LI> <LI> <p class="outputTextNB"><strong>Quality Improvement Strategy.</strong> <strong>Appendix H</strong> contains the Quality Improvement Strategy for this waiver.</p> </LI> <LI> <p class="outputTextNB"><strong>Financial Accountability.</strong> <strong>Appendix I</strong> describes the methods by which the State makes payments for waiver services, ensures the integrity of these payments, and complies with applicable federal requirements concerning payments and federal financial participation.</p> </LI> <LI> <p class="outputTextNB"><strong>Cost-Neutrality Demonstration.</strong> <strong>Appendix J</strong> contains the State's demonstration that the waiver is cost-neutral.</p> </LI> </OL> <H2 id="pageTitle">4. Waiver(s) Requested</H2> <OL class="alpha"> <LI> <div class="outputTextNB"><strong>Comparability.</strong> The State requests a waiver of the requirements contained in §1902(a)(10)(B) of the Act in order to provide the services specified in <strong>Appendix C</strong> that are not otherwise available under the approved Medicaid State plan to individuals who: (a) require the level(s) of care specified in Item 1.F and (b) meet the target group criteria specified in <strong>Appendix B</strong>. </div> </LI> <LI> <div class="outputTextNB" > <strong>Income and Resources for the Medically Needy.</strong> Indicate whether the State requests a waiver of §1902(a)(10)(C)(i)(III) of the Act in order to use institutional income and resource rules for the medically needy <em>(select one)</em>: </div> <div> <div class="checkboxGroup"><label><input id="svwaiverReq:incRes1902a:2" type="radio" name="svwaiverReq:incRes1902a" checked="checked" value="2" disabled="disabled" />&#160;Not Applicable</label></div> <div class="checkboxGroup"><label><input id="svwaiverReq:incRes1902a:0" type="radio" name="svwaiverReq:incRes1902a" value="0" disabled="disabled" />&#160;No</label></div> <div class="checkboxGroup"><label><input id="svwaiverReq:incRes1902a:1" type="radio" name="svwaiverReq:incRes1902a" value="1" disabled="disabled" />&#160;Yes</label></div> <div class="noShow"><label><input id="svwaiverReq:incRes1902a:3" type="radio" name="svwaiverReq:incRes1902a" value="99" disabled="disabled" />&#160;not selected</label></div> </div> </LI> <LI> <div class="outputTextNB"> <strong>Statewideness.</strong> Indicate whether the State requests a waiver of the statewideness requirements in §1902(a)(1) of the Act <em>(select one)</em>: </div> <div> <table id="svwaiverReq:statewide" class="selectOneRadio"> <tr> <td> <input type="radio" checked="checked" name="svwaiverReq:statewide" id="svwaiverReq:statewide:0" value="0" onclick="return callSave(this, event);" disabled="disabled" /><label for="svwaiverReq:statewide:0"> No</label></td> </tr> <tr> <td> <input type="radio" name="svwaiverReq:statewide" id="svwaiverReq:statewide:1" value="1" onclick="return callSave(this, event);" disabled="disabled" /><label for="svwaiverReq:statewide:1"> Yes</label></td> </tr> </table> </div> <div class="firstIndent"> <div class="outputTextNB"> If yes, specify the waiver of statewideness that is requested <em>(check each that applies)</em>: </div> <div class="checkboxGroup" > <input id="svwaiverReq:swideGeoLim" type="checkbox" name="svwaiverReq:swideGeoLim" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svwaiverReq:lbl_swideGeoLim" for="svwaiverReq:swideGeoLim" class="outputLabel"> <span id="svwaiverReq:txt_lbl_swideGeoLim1" class="outputText">Geographic Limitation. </span><span id="svwaiverReq:txt_lbl_swideGeoLim2" class="outputTextNB">A waiver of statewideness is requested in order to furnish services under this waiver only to individuals who reside in the following geographic areas or political subdivisions of the State. </span></label> </div> <div class="firstIndent"> <div> <label id="svwaiverReq:lbl_swideGeoLimDesc" for="svwaiverReq:swideGeoLimDesc" class="outputLabel"> <span id="svwaiverReq:txt_lbl_swideGeoLimDesc" class="outputTextNB em">Specify the areas to which this waiver applies and, as applicable, the phase-in schedule of the waiver by geographic area:</span></label> </div> <div></div> <div class="chrCntDiv"> <label id="svwaiverReq:swideGeoLimDescChrCntLbl" for="svwaiverReq:swideGeoLimDescChrCnt" class="outputLabel"> <span id="svwaiverReq:swideGeoLimDescChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svwaiverReq:swideGeoLimDescChrCnt" type="text" name="svwaiverReq:swideGeoLimDescChrCnt" class="chrCnt" size="6" /><span id="svwaiverReq:swideGeoLimDescChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svwaiverReq:panel_swideGeoLimDesc"><textarea id="svwaiverReq:swideGeoLimDesc" name="svwaiverReq:swideGeoLimDesc" class="inputTextarea15" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="checkboxGroup"> <input id="svwaiverReq:swidePDLim" type="checkbox" name="svwaiverReq:swidePDLim" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svwaiverReq:lbl_swidePDLim" for="svwaiverReq:swidePDLim" class="outputLabel"> <span id="svwaiverReq:txt_lbl_swidePDLim1" class="outputText">Limited Implementation of Participant-Direction. </span><span id="svwaiverReq:txt_lbl_swidePDLim2" class="outputTextNB"> A waiver of statewideness is requested in order to make </span><span id="svwaiverReq:txt_lbl_swidePDLim3" class="outputTextNB em">participant-direction of services </span><span id="svwaiverReq:txt_lbl_swidePDLim4" class="outputTextNB">as specified in </span><span id="svwaiverReq:txt_lbl_swidePDLim5" class="outputText">Appendix E </span><span id="svwaiverReq:txt_lbl_swidePDLim6" class="outputTextNB">available only to individuals who reside in the following geographic areas or political subdivisions of the State. Participants who reside in these areas may elect to direct their services as provided by the State or receive comparable services through the service delivery methods that are in effect elsewhere in the State.</span></label> </div> <div class="firstIndent"> <div> <label id="svwaiverReq:lbl_swidePDLimDesc" for="svwaiverReq:swidePDLimDesc" class="outputLabel"> <span id="svwaiverReq:txt_lbl_swidePDLimDesc" class="outputTextNB em">Specify the areas of the State affected by this waiver and, as applicable, the phase-in schedule of the waiver by geographic area:</span></label> </div> <div></div> <div class="chrCntDiv"> <label id="svwaiverReq:swidePDLimDescChrCntLbl" for="svwaiverReq:swidePDLimDescChrCnt" class="outputLabel"> <span id="svwaiverReq:swidePDLimDescChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svwaiverReq:swidePDLimDescChrCnt" type="text" name="svwaiverReq:swidePDLimDescChrCnt" class="chrCnt" size="6" /><span id="svwaiverReq:swidePDLimDescChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svwaiverReq:panel_swidePDLimDesc"><textarea id="svwaiverReq:swidePDLimDesc" name="svwaiverReq:swidePDLimDesc" class="inputTextarea15" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> </div> </LI> </OL> <H2 id="pageTitle">5. Assurances</H2> <div id="pageDesc">In accordance with 42 CFR §441.302, the State provides the following assurances to CMS:</div> <OL class="alpha"> <LI> <p class="outputTextNB"><strong>Health &amp; Welfare:</strong> The State assures that necessary safeguards have been taken to protect the health and welfare of persons receiving services under this waiver. These safeguards include: </p> <OL class="numeric"> <LI> <p class="outputTextNB">As specified in <strong>Appendix C</strong>, adequate standards for all types of providers that provide services under this waiver;</p> </LI> <LI> <p class="outputTextNB">Assurance that the standards of any State licensure or certification requirements specified in <strong>Appendix C</strong> are met for services or for individuals furnishing services that are provided under the waiver. The State assures that these requirements are met on the date that the services are furnished; and,</p> </LI> <LI> <p class="outputTextNB">Assurance that all facilities subject to §1616(e) of the Act where home and community-based waiver services are provided comply with the applicable State standards for board and care facilities as specified in <strong>Appendix C</strong>.</p> </LI> </OL> </LI> <LI> <p class="outputTextNB"><strong>Financial Accountability.</strong> The State assures financial accountability for funds expended for home and community-based services and maintains and makes available to the Department of Health and Human Services (including the Office of the Inspector General), the Comptroller General, or other designees, appropriate financial records documenting the cost of services provided under the waiver. Methods of financial accountability are specified in <strong>Appendix I</strong>.</p> </LI> <LI> <p class="outputTextNB"><strong>Evaluation of Need:</strong> The State assures that it provides for an initial evaluation (and periodic reevaluations, at least annually) of the need for a level of care specified for this waiver, when there is a reasonable indication that an individual might need such services in the near future (one month or less) but for the receipt of home and community-based services under this waiver. The procedures for evaluation and reevaluation of level of care are specified in <strong>Appendix B</strong>.</p> </LI> <LI> <p class="outputTextNB">Choice of Alternatives: The State assures that when an individual is determined to be likely to require the level of care specified for this waiver and is in a target group specified in <strong>Appendix B</strong>, the individual (or, legal representative, if applicable) is:</p> <OL class="numeric"> <LI> <p class="outputTextNB">Informed of any feasible alternatives under the waiver; and,</p> </LI> <LI> <p class="outputTextNB">Given the choice of either institutional or home and community-based waiver services. <strong>Appendix B</strong> specifies the procedures that the State employs to ensure that individuals are informed of feasible alternatives under the waiver and given the choice of institutional or home and community-based waiver services.</p> </LI> </OL> </LI> <LI> <p class="outputTextNB"><strong>Average Per Capita Expenditures:</strong> The State assures that, for any year that the waiver is in effect, the average per capita expenditures under the waiver will not exceed 100 percent of the average per capita expenditures that would have been made under the Medicaid State plan for the level(s) of care specified for this waiver had the waiver not been granted. Cost-neutrality is demonstrated in <strong>Appendix J</strong>.</p> </LI> <LI> <p class="outputTextNB"><strong>Actual Total Expenditures:</strong> The State assures that the actual total expenditures for home and community-based waiver and other Medicaid services and its claim for FFP in expenditures for the services provided to individuals under the waiver will not, in any year of the waiver period, exceed 100 percent of the amount that would be incurred in the absence of the waiver by the State's Medicaid program for these individuals in the institutional setting(s) specified for this waiver.</p> </LI> <LI> <p class="outputTextNB"><strong>Institutionalization Absent Waiver:</strong> The State assures that, absent the waiver, individuals served in the waiver would receive the appropriate type of Medicaid-funded institutional care for the level of care specified for this waiver.</p> </LI> <LI> <p class="outputTextNB"><strong>Reporting:</strong> The State assures that annually it will provide CMS with information concerning the impact of the waiver on the type, amount and cost of services provided under the Medicaid State plan and on the health and welfare of waiver participants. This information will be consistent with a data collection plan designed by CMS.</p> </LI> <LI> <p class="outputTextNB"><strong>Habilitation Services.</strong> The State assures that prevocational, educational, or supported employment services, or a combination of these services, if provided as habilitation services under the waiver are: (1) not otherwise available to the individual through a local educational agency under the Individuals with Disabilities Education Act (IDEA) or the Rehabilitation Act of 1973; and, (2) furnished as part of expanded habilitation services.</p> </LI> <LI> <p class="outputTextNB"><strong>Services for Individuals with Chronic Mental Illness.</strong> The State assures that federal financial participation (FFP) will not be claimed in expenditures for waiver services including, but not limited to, day treatment or partial hospitalization, psychosocial rehabilitation services, and clinic services provided as home and community-based services to individuals with chronic mental illnesses if these individuals, in the absence of a waiver, would be placed in an IMD and are: (1) age 22 to 64; (2) age 65 and older and the State has not included the optional Medicaid benefit cited in 42 CFR §440.140; or (3) age 21 and under and the State has not included the optional Medicaid benefit cited in 42 CFR § 440.160.</p> </LI> </OL> <H2 id="pageTitle">6. Additional Requirements</H2> <DIV id="pageDesc" class="em">Note: Item 6-I must be completed.</DIV> <OL type="A" class="alpha"> <LI> <p class="outputTextNB"><strong>Service Plan</strong>. In accordance with 42 CFR §441.301(b)(1)(i), a participant-centered service plan (of care) is developed for each participant employing the procedures specified in <strong>Appendix D</strong>. All waiver services are furnished pursuant to the service plan. The service plan describes: (a) the waiver services that are furnished to the participant, their projected frequency and the type of provider that furnishes each service and (b) the other services (regardless of funding source, including State plan services) and informal supports that complement waiver services in meeting the needs of the participant. The service plan is subject to the approval of the Medicaid agency. Federal financial participation (FFP) is not claimed for waiver services furnished prior to the development of the service plan or for services that are not included in the service plan.</p> </LI> <LI> <p class="outputTextNB"><strong>Inpatients</strong>. In accordance with 42 CFR §441.301(b)(1)(ii), waiver services are not furnished to individuals who are in-patients of a hospital, nursing facility or ICF/IID.</p> </LI> <LI> <p class="outputTextNB"><strong>Room and Board</strong>. In accordance with 42 CFR §441.310(a)(2), FFP is not claimed for the cost of room and board except when: (a) provided as part of respite services in a facility approved by the State that is not a private residence or (b) claimed as a portion of the rent and food that may be reasonably attributed to an unrelated caregiver who resides in the same household as the participant, as provided in <strong>Appendix I</strong>. </p> </LI> <LI> <p class="outputTextNB"><strong>Access to Services</strong>. The State does not limit or restrict participant access to waiver services except as provided in <strong>Appendix C</strong>. </p> </LI> <LI> <p class="outputTextNB"><strong>Free Choice of Provider</strong>. In accordance with 42 CFR §431.151, a participant may select any willing and qualified provider to furnish waiver services included in the service plan unless the State has received approval to limit the number of providers under the provisions of §1915(b) or another provision of the Act. </p> </LI> <LI> <p class="outputTextNB"><strong>FFP Limitation</strong>. In accordance with 42 CFR §433 Subpart D, FFP is not claimed for services when another third-party (e.g., another third party health insurer or other federal or state program) is legally liable and responsible for the provision and payment of the service. FFP also may not be claimed for services that are available without charge, or as free care to the community. Services will not be considered to be without charge, or free care, when (1) the provider establishes a fee schedule for each service available and (2) collects insurance information from all those served (Medicaid, and non-Medicaid), and bills other legally liable third party insurers. Alternatively, if a provider certifies that a particular legally liable third party insurer does not pay for the service(s), the provider may not generate further bills for that insurer for that annual period. </p> </LI> <LI> <p class="outputTextNB"><strong>Fair Hearing:</strong> The State provides the opportunity to request a Fair Hearing under 42 CFR §431 Subpart E, to individuals: (a) who are not given the choice of home and community-based waiver services as an alternative to institutional level of care specified for this waiver; (b) who are denied the service(s) of their choice or the provider(s) of their choice; or (c) whose services are denied, suspended, reduced or terminated. <strong>Appendix F</strong> specifies the State's procedures to provide individuals the opportunity to request a Fair Hearing, including providing notice of action as required in 42 CFR §431.210. </p> </LI> <LI> <p class="outputTextNB"><strong>Quality Improvement</strong>. The State operates a formal, comprehensive system to ensure that the waiver meets the assurances and other requirements contained in this application. Through an ongoing process of discovery, remediation and improvement, the State assures the health and welfare of participants by monitoring: (a) level of care determinations; (b) individual plans and services delivery; (c) provider qualifications; (d) participant health and welfare; (e) financial oversight and (f) administrative oversight of the waiver. The State further assures that all problems identified through its discovery processes are addressed in an appropriate and timely manner, consistent with the severity and nature of the problem. During the period that the waiver is in effect, the State will implement the Quality Improvement Strategy specified in <strong>Appendix H</strong>. </p> </LI> <LI> <div> <span class="outputText bld">Public Input. </span> <label id="svadditionalReq:lbl_publicInput" for="svadditionalReq:publicInput" class="outputLabel"> <span id="svadditionalReq:txt_lbl_publicInput" class="outputTextNB">Describe how the State secures public input into the development of the waiver:</span></label> </div> <div></div> <div class="chrCntDiv"> <label id="svadditionalReq:publicInputChrCntLbl" for="svadditionalReq:publicInputChrCnt" class="outputLabel"> <span id="svadditionalReq:publicInputChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svadditionalReq:publicInputChrCnt" type="text" name="svadditionalReq:publicInputChrCnt" class="chrCnt" size="6" /><span id="svadditionalReq:publicInputChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svadditionalReq:panel_publicInput"><textarea id="svadditionalReq:publicInput" name="svadditionalReq:publicInput" class="inputTextareaLong" onkeyup="Count(this);" readonly="readonly">To ensure public input into the development of the Waiver the state has had representation at: 1. Connecticut Council for Persons with Disabilities, as mandated by CGS 17b 606. 2. PCA Satisfaction Survey 3. Phone interviews 4. Annual survey A notice of intent to renew the waiver was published in the CT Law Journal and the 2 local tribes were also notified. The same process was followed for the amendment. Notice was published requesting comments for a 30 day period. No comments were received In addition, the notice was published on the department's web site outlining the proposed changes.</textarea></span> </div> </LI> <LI> <p class="outputTextNB"><strong>Notice to Tribal Governments</strong>. The State assures that it has notified in writing all federally-recognized Tribal Governments that maintain a primary office and/or majority population within the State of the State's intent to submit a Medicaid waiver request or renewal request to CMS at least 60 days before the anticipated submission date is provided by Presidential Executive Order 13175 of November 6, 2000. Evidence of the applicable notice is available through the Medicaid Agency. </p> </LI> <LI> <p class="outputTextNB"><strong>Limited English Proficient Persons</strong>. The State assures that it provides meaningful access to waiver services by Limited English Proficient persons in accordance with: (a) Presidential Executive Order 13166 of August 11, 2000 (65 FR 50121) and (b) Department of Health and Human Services "Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons" (68 FR 47311 - August 8, 2003). <strong>Appendix B</strong> describes how the State assures meaningful access to waiver services by Limited English Proficient persons. </p> </LI> </OL> <LINK rel="stylesheet" type="text/css" href="/WMS/theme/twoColTable.css" media="print,screen"> <H2 id="pageTitle">7. Contact Person(s)</H2> <OL class="alpha" style="clear: both;"> <LI style="clear: both;"> <div class="outputTextNB">The Medicaid agency representative with whom CMS should communicate regarding the waiver is:</div> <div class="tblContacts" style="margin-bottom:3em;padding-bottom:1em;"> <div class="rowContact"> <div class="leftColFixed100 qLabel"> <label id="svcontact:lbl_stMedRepLName" for="svcontact:stMedRepLName" class="outputLabel"> <span id="svcontact:txt_lbl_stMedRepLName" class="outputText">Last Name:</span></label> </div> <div class="rightCol80"> <p></p> <input id="svcontact:stMedRepLName" type="text" name="svcontact:stMedRepLName" value="Bruni" class="inputText" readonly="readonly" /> </div> </div> <div class="rowContact"> <div class="leftColFixed100 qLabel" style="margin-left:0;margin-right:0;"> <label id="svcontact:lbl_stMedRepFName" for="svcontact:stMedRepFName" class="outputLabel"> <span id="svcontact:txt_lbl_stMedRepFName" class="outputText">First Name:</span></label> </div> <div class="rightCol80"> <p></p> <input id="svcontact:stMedRepFName" type="text" name="svcontact:stMedRepFName" value="Kathy" class="inputText" readonly="readonly" /> </div> </div> <div class="rowContact"> <div class="leftColFixed100 qLabel"> <label id="svcontact:lbl_stMedRepTitle" for="svcontact:stMedRepTitle" class="outputLabel"> <span id="svcontact:txt_lbl_stMedRepTitle" class="outputText">Title:</span></label> </div> <div class="rightCol80"> <p></p> <input id="svcontact:stMedRepTitle" type="text" name="svcontact:stMedRepTitle" value="Director, Home and Community Based Services Unit" class="inputTextLong" readonly="readonly" /> </div> </div> <div class="rowContact"> <div class="leftColFixed100 qLabel"> <label id="svcontact:lbl_stMedRepAg" for="svcontact:stMedRepAg" class="outputLabel"> <span id="svcontact:txt_lbl_stMedRepAg" class="outputText">Agency:</span></label> </div> <div class="rightCol80"> <p></p> <input id="svcontact:stMedRepAg" type="text" name="svcontact:stMedRepAg" value="Department of Social Services" class="inputTextLong" readonly="readonly" /> </div> </div> <div class="rowContact"> <div class="leftColFixed100 qLabel"> <label id="svcontact:lbl_stMedRepAdd1" for="svcontact:stMedRepAdd1" class="outputLabel"> <span id="svcontact:txt_lbl_stMedRepAdd1" class="outputText">Address:</span></label> </div> <div class="rightCol80"> <p></p> <input id="svcontact:stMedRepAdd1" type="text" name="svcontact:stMedRepAdd1" value="55 Farmington Ave" class="inputTextLong" readonly="readonly" /> </div> </div> <div class="rowContact"> <div class="leftColFixed100 qLabel"> <label id="svcontact:lbl_stMedRepAdd2" for="svcontact:stMedRepAdd2" class="outputLabel"> <span id="svcontact:txt_lbl_stMedRepAdd2" class="outputText">Address 2:</span></label> </div> <div class="rightCol80"> <p></p> <input id="svcontact:stMedRepAdd2" type="text" name="svcontact:stMedRepAdd2" class="inputTextLong" readonly="readonly" /> </div> </div> <div class="rowContact"> <div class="leftColFixed100 qLabel"> <label id="svcontact:lbl_stMedRepCity" for="svcontact:stMedRepCity" class="outputLabel"> <span id="svcontact:txt_lbl_stMedRepCity" class="outputText">City:</span></label> </div> <div class="rightCol80"> <p></p> <input id="svcontact:stMedRepCity" type="text" name="svcontact:stMedRepCity" value="Hartford" class="inputText" readonly="readonly" /> </div> </div> <div class="rowContact"> <div class="leftColFixed100 qLabel"> <label id="svcontact:lbl_stMedRepState" for="svcontact:stMedRepState" class="outputLabel"> <span id="svcontact:txt_lbl_stMedRepState" class="outputText">State:</span></label> </div> <div class="rightCol80"> <span id="svcontact:stMedRepState" class="outputText">Connecticut</span> </div> </div> <div class="rowContact"> <div class="leftColFixed100 qLabel"> <label id="svcontact:lbl_stMedRepZip" for="svcontact:stMedRepZip" class="outputLabel"> <span id="svcontact:txt_lbl_stMedRepZip" class="outputText">Zip:</span></label> </div> <div class="rightCol80"> <p></p> <p> <input id="svcontact:stMedRepZip" type="text" name="svcontact:stMedRepZip" value="06105" class="inputText4em" maxlength="10" size="10" readonly="readonly" /> </p> </div> </div> <div class="rowContact"> <div class="leftColFixed100 qLabel"> <label id="svcontact:lbl_stMedRepTel" for="svcontact:stMedRepTel" class="outputLabel"> <span id="svcontact:txt_lbl_stMedRepTel" class="outputText">Phone:</span></label> </div> <div class="rightCol80"> <p></p> <p></p> <p> <input id="svcontact:stMedRepTel" type="text" name="svcontact:stMedRepTel" value="(860) 424-5177" class="inputText" maxlength="15" size="15" title="phone number" readonly="readonly" /><label id="svcontact:lbl_stMedRepTelExt" for="svcontact:stMedRepTelExt" class="outputLabel"> <span id="svcontact:lbltxt_stMedRepTelExt" class="outputText qLabel"> Ext:</span></label><input id="svcontact:stMedRepTelExt" type="text" name="svcontact:stMedRepTelExt" class="inputText4EM" maxlength="5" size="5" title="phone number extension" readonly="readonly" /><input id="svcontact:stMedRepTelTty" type="checkbox" name="svcontact:stMedRepTelTty" class="selectBooleanCheckbox" style="vertical-align: middle;" disabled="disabled" /><label id="svcontact:lbl_stMedRepTelTty" for="svcontact:stMedRepTelTty" class="outputLabel"> <span id="svcontact:txt_lbl_stMedRepTelTty" class="outputText qLabel">TTY</span></label> </p> </div> </div> <div class="rowContact"> <div class="leftColFixed100 qLabel"> <label id="svcontact:lbl_stMedRepFax" for="svcontact:stMedRepFax" class="outputLabel"> <span id="svcontact:lbltxt_stMedRepFax" class="outputText">Fax:</span></label> </div> <div class="rightCol80"> <p></p> <p> <input id="svcontact:stMedRepFax" type="text" name="svcontact:stMedRepFax" value="(860) 424-4963" class="inputText" maxlength="15" size="15" title="fax number" readonly="readonly" /> </p> </div> </div> <div class="rowContact"> <div class="qLabel leftColFixed100"> <label id="svcontact:lbl_stMedRepEmail" for="svcontact:stMedRepEmail" class="outputLabel"> <span id="svcontact:txt_lbl_stMedRepEmail" class="outputText">E-mail:</span></label> </div> <div class="rightCol80"> <p></p> <input id="svcontact:stMedRepEmail" type="text" name="svcontact:stMedRepEmail" value="kathy.a.bruni@ct.gov" class="inputTextLong" readonly="readonly" /> </div> </div> </div> </LI> <LI style="clear: both; padding-top:2em;"> <div class="outputTextNB">If applicable, the State operating agency representative with whom CMS should communicate regarding the waiver is:</div> <div class="tblContacts" style="margin-bottom:3em;padding-bottom:1em;" id="contactsB"> <div class="rowContact"> <div class="qLabel leftColFixed100" > <label id="svcontact:lbl_stOpAgRepLName" for="svcontact:stOpAgRepLName" class="outputLabel"> <span id="svcontact:txt_lbl_stOpAgRepLName" class="outputText">Last Name:</span></label> </div> <div class="rightCol80"> <p></p> <input id="svcontact:stOpAgRepLName" type="text" name="svcontact:stOpAgRepLName" class="inputText" readonly="readonly" /> </div> </div> <div class="rowContact"> <div class="qLabel leftColFixed100"> <label id="svcontact:lbl_stOpAgRepFName" for="svcontact:stOpAgRepFName" class="outputLabel"> <span id="svcontact:txt_lbl_stOpAgRepFName" class="outputText">First Name:</span></label> </div> <div class="rightCol80"> <p></p> <input id="svcontact:stOpAgRepFName" type="text" name="svcontact:stOpAgRepFName" class="inputText" readonly="readonly" /> </div> </div> <div class="rowContact"> <div class="qLabel leftColFixed100"> <label id="svcontact:lbl_stOpAgRepTitle" for="svcontact:stOpAgRepTitle" class="outputLabel"> <span id="svcontact:txt_lbl_stOpAgRepTitle" class="outputText">Title:</span></label> </div> <div class="rightCol80"> <p></p> <input id="svcontact:stOpAgRepTitle" type="text" name="svcontact:stOpAgRepTitle" class="inputTextLong" readonly="readonly" /> </div> </div> <div class="rowContact"> <div class="qLabel leftColFixed100"> <label id="svcontact:lbl_stOpAgRepAg" for="svcontact:stOpAgRepAg" class="outputLabel"> <span id="svcontact:txt_lbl_stOpAgRepAg" class="outputText">Agency:</span></label> </div> <div class="rightCol80"> <p></p> <input id="svcontact:stOpAgRepAg" type="text" name="svcontact:stOpAgRepAg" class="inputTextLong" readonly="readonly" /> </div> </div> <div class="rowContact"> <div class="qLabel leftColFixed100"> <label id="svcontact:lbl_stOpAgRepAdd1" for="svcontact:stOpAgRepAdd1" class="outputLabel"> <span id="svcontact:txt_lbl_stOpAgRepAdd1" class="outputText">Address:</span></label> </div> <div class="rightCol80"> <p></p> <input id="svcontact:stOpAgRepAdd1" type="text" name="svcontact:stOpAgRepAdd1" class="inputTextLong" readonly="readonly" /> </div> </div> <div class="rowContact"> <div class="qLabel leftColFixed100"> <label id="svcontact:lbl_stOpAgRepAdd2" for="svcontact:stOpAgRepAdd2" class="outputLabel"> <span id="svcontact:txt_lbl_stOpAgRepAdd2" class="outputText">Address 2:</span></label> </div> <div class="rightCol80"> <p></p> <input id="svcontact:stOpAgRepAdd2" type="text" name="svcontact:stOpAgRepAdd2" class="inputTextLong" readonly="readonly" /> </div> </div> <div class="rowContact"> <div class="qLabel leftColFixed100"> <label id="svcontact:lbl_stOpAgRepCity" for="svcontact:stOpAgRepCity" class="outputLabel"> <span id="svcontact:txt_lbl_stOpAgRepCity" class="outputText">City:</span></label> </div> <div class="rightCol80"> <p></p> <input id="svcontact:stOpAgRepCity" type="text" name="svcontact:stOpAgRepCity" class="inputText" readonly="readonly" /> </div> </div> <div class="rowContact"> <div class="qLabel leftColFixed100"> <label id="svcontact:lbl_stOpAgRepState" for="svcontact:stOpAgRepState" class="outputLabel"> <span id="svcontact:txt_lbl_stOpAgRepState" class="outputText">State:</span></label> </div> <div class="rightCol80"> <span id="svcontact:stOpAgRepState" class="outputText">Connecticut</span> </div> </div> <div class="rowContact"> <div class="qLabel leftColFixed100"> <label id="svcontact:lbl_stOpAgRepZip" for="svcontact:stOpAgRepZip" class="outputLabel"> <span id="svcontact:txt_lbl_stOpAgRepZip" class="outputText">Zip:</span></label> </div> <div class="rightCol80"> <p></p> <p> <input id="svcontact:stOpAgRepZip" type="text" name="svcontact:stOpAgRepZip" class="inputText5em" maxlength="11" size="11" readonly="readonly" /> </p> </div> </div> <div class="rowContact"> <div class="qLabel leftColFixed100"> <label id="svcontact:lbl_stOpAgRepTel" for="svcontact:stOpAgRepTel" class="outputLabel"> <span id="svcontact:lbltxt_stOpAgRepTel" class="outputText">Phone:</span></label> </div> <div class="rightCol80"> <p></p> <p></p> <p> <input id="svcontact:stOpAgRepTel" type="text" name="svcontact:stOpAgRepTel" class="inputText" maxlength="15" size="15" title="phone number" readonly="readonly" /><label id="svcontact:lbl_stOpAgRepTelExt" for="svcontact:stOpAgRepTelExt" class="outputLabel"> <span id="svcontact:lbltxt_stOpAgRepTelExt" class="outputText qLabel"> Ext:</span></label><input id="svcontact:stOpAgRepTelExt" type="text" name="svcontact:stOpAgRepTelExt" class="inputText4EM" maxlength="5" size="5" title="phone number extension" readonly="readonly" /><input id="svcontact:stOpAgRepTelTty" type="checkbox" name="svcontact:stOpAgRepTelTty" class="selectBooleanCheckbox" style="vertical-align: middle;" disabled="disabled" /><label id="svcontact:lbl_stOpAgRepTelTty" for="svcontact:stOpAgRepTelTty" class="outputLabel"> <span id="svcontact:txt_lbl_stOpAgRepTelTty" class="outputText qLabel">TTY</span></label> </p> </div> </div> <div class="rowContact"> <div class="qLabel leftColFixed100"> <label id="svcontact:lbl_stOpAgRepFax" for="svcontact:stOpAgRepFax" class="outputLabel"> <span id="svcontact:lbltxt_stOpAgRepFax" class="outputText">Fax:</span></label> </div> <div class="rightCol80"> <p></p> <p> <input id="svcontact:stOpAgRepFax" type="text" name="svcontact:stOpAgRepFax" class="inputText" maxlength="15" size="15" title="fax number" readonly="readonly" /> </p> </div> </div> <div class="rowContact"> <div class="qLabel leftColFixed100"> <label id="svcontact:lbl_stOpAgRepEmail" for="svcontact:stOpAgRepEmail" class="outputLabel"> <span id="svcontact:txt_lbl_stOpAgRepEmail" class="outputText">E-mail:</span></label> </div> <div class="rightCol80"> <p></p> <input id="svcontact:stOpAgRepEmail" type="text" name="svcontact:stOpAgRepEmail" class="inputTextLong" readonly="readonly" /> </div> </div> </div> </LI> </OL> <LINK rel="stylesheet" type="text/css" href="/WMS/theme/twoColTable.css" media="print,screen"> <H2 id="pageTitle">8. Authorizing Signature</H2> <div class="paragraph"> <div class="paragraph"> </div> <div class="paragraph"> <span id="svauthorization:amendmentText" class="outputTextNB">This document, together with the attached revisions to the affected components of the waiver, constitutes the State's request to amend its approved waiver under &sect;1915(c) of the Social Security Act. The State affirms that it will abide by all provisions of the waiver, including the provisions of this amendment when approved by CMS. The State further attests that it will continuously operate the waiver in accordance with the assurances specified in Section V and the additional requirements specified in Section VI of the approved waiver. The State certifies that additional proposed revisions to the waiver request will be submitted by the Medicaid agency in the form of additional waiver amendments.</span> </div> </div> <div id="tblAuth" class="tblContacts outputText pph underline" style="clear:both;"> <div class="rowContact"> <div class="leftColFixed100 qLabel"> <label id="svauthorization:lbl_stMedDirFullName" for="svauthorization:stMedDirFullName" class="outputLabel"> <span id="svauthorization:txt_lbl_stMedDirFullName" class="outputText">Signature:</span></label> </div> <div class="rightCol80"> <input id="svauthorization:stMedDirFullName" type="text" name="svauthorization:stMedDirFullName" class="inputText" readonly="readonly" /> </div> </div> <div class="rowContact"> <div class="leftColFixed100 qLabel"></div> <div class="rightCol80"> <p class="outputTextNB">State Medicaid Director or Designee</p> </div> </div> <div class="rowContact"> <div class="leftColFixed100 qLabel"> <label id="svauthorization:lbl_stMedDirSgnDt" for="svauthorization:stMedDirSgnDt" class="outputLabel"> <span id="svauthorization:txt_lbl_stMedDirSgnDte" class="outputText">Submission Date:</span></label> </div> <div class="rightCol80"> <input id="svauthorization:stMedDirSgnDt" type="text" name="svauthorization:stMedDirSgnDt" class="inputText" readonly="readonly" /> </div> </div> <div class="rowContact"> <div class="leftColFixed100 qLabel"></div> <div class="rightCol80"> <div class="pph rightAlign"> <span id="svauthorization:jspPanelShowErrors" class="noShow"></span> </div> </div> </div> <div class="rowContact"> <div class="leftColFixed100 qLabel"></div> <div class="rightCol80"> <span id="svauthorization:txt_stMedDirSigDateNote" class="outputText">Note: The Signature and Submission Date fields will be automatically completed when the State Medicaid Director submits the application.</span> </div> </div> </div> <div id="tblAuth2" class="tblContacts" style="clear:both;"> <div class="rowContact"> <div class="leftColFixed100 qLabel"> <label id="svauthorization:lbl_stMedDirLName" for="svauthorization:stMedDirLName" class="outputLabel"> <span id="svauthorization:txt_lbl_stMedDirLName" class="outputText">Last Name:</span></label> </div> <div class="rightCol80"> <p></p> <input id="svauthorization:stMedDirLName" type="text" name="svauthorization:stMedDirLName" class="inputText" readonly="readonly" /> </div> </div> <div class="rowContact"> <div class="leftColFixed100 qLabel"> <label id="svauthorization:lbl_stMedDirFName" for="svauthorization:stMedDirFName" class="outputLabel"> <span id="svauthorization:txt_lbl_stMedDirFName" class="outputText">First Name:</span></label> </div> <div class="rightCol80"> <p></p> <input id="svauthorization:stMedDirFName" type="text" name="svauthorization:stMedDirFName" class="inputText" readonly="readonly" /> </div> </div> <div class="rowContact"> <div class="leftColFixed100 qLabel"> <label id="svauthorization:lbl_stMedDirTitle" for="svauthorization:stMedDirTitle" class="outputLabel"> <span id="svauthorization:txt_lbl_stMedDirTitle" class="outputText">Title:</span></label> </div> <div class="rightCol80"> <p></p> <input id="svauthorization:stMedDirTitle" type="text" name="svauthorization:stMedDirTitle" class="inputTextLong" readonly="readonly" /> </div> </div> <div class="rowContact"> <div class="leftColFixed100 qLabel"> <label id="svauthorization:lbl_stMedDirAg" for="svauthorization:stMedDirAg" class="outputLabel"> <span id="svauthorization:txt_lbl_stMedDirAg" class="outputText">Agency:</span></label> </div> <div class="rightCol80"> <p></p> <input id="svauthorization:stMedDirAg" type="text" name="svauthorization:stMedDirAg" class="inputTextLong" readonly="readonly" /> </div> </div> <div class="rowContact"> <div class="leftColFixed100 qLabel"> <label id="svauthorization:lbl_stMedDirAdd1" for="svauthorization:stMedDirAdd1" class="outputLabel"> <span id="svauthorization:txt_lbl_stMedDirAdd1" class="outputText">Address:</span></label> </div> <div class="rightCol80"> <p></p> <input id="svauthorization:stMedDirAdd1" type="text" name="svauthorization:stMedDirAdd1" class="inputTextLong" readonly="readonly" /> </div> </div> <div class="rowContact"> <div class="leftColFixed100 qLabel"> <label id="svauthorization:lbl_stMedDirAdd2" for="svauthorization:stMedDirAdd2" class="outputLabel"> <span id="svauthorization:txt_lbl_stMedDirAdd2" class="outputText">Address 2:</span></label> </div> <div class="rightCol80"> <p></p> <input id="svauthorization:stMedDirAdd2" type="text" name="svauthorization:stMedDirAdd2" class="inputTextLong" readonly="readonly" /> </div> </div> <div class="rowContact"> <div class="leftColFixed100 qLabel"> <label id="svauthorization:lbl_stMedDirCity" for="svauthorization:stMedDirCity" class="outputLabel"> <span id="svauthorization:txt_lbl_stMedDirCity" class="outputText">City:</span></label> </div> <div class="rightCol80"> <p></p> <input id="svauthorization:stMedDirCity" type="text" name="svauthorization:stMedDirCity" class="inputText" readonly="readonly" /> </div> </div> <div class="rowContact"> <div class="leftColFixed100 qLabel"> <label id="svauthorization:lbl_stMedDirState" for="svauthorization:stMedDirState" class="outputLabel"> <span id="svauthorization:txt_lbl_stMedDirLState" class="outputText">State:</span></label> </div> <div class="rightCol80"> <span id="svauthorization:stMedDirState" class="outputText">Connecticut</span> </div> </div> <div class="rowContact"> <div class="leftColFixed100 qLabel"> <label id="svauthorization:lbl_stMedDirZip" for="svauthorization:stMedDirZip" class="outputLabel"> <span id="svauthorization:txt_lbl_stMedDirZip" class="outputText">Zip:</span></label> </div> <div class="rightCol80"> <p></p> <p> <input id="svauthorization:stMedDirZip" type="text" name="svauthorization:stMedDirZip" class="inputText" maxlength="11" size="11" readonly="readonly" /> </p> </div> </div> <div class="rowContact"> <div class="leftColFixed100 qLabel"> <label id="svauthorization:lbl_stMedDirTel" for="svauthorization:stMedDirTel" class="outputLabel"> <span id="svauthorization:lbltxt_stMedDirTel" class="outputText">Phone:</span></label> </div> <div class="rightCol80"> <p></p> <p></p> <p> <input id="svauthorization:stMedDirTel" type="text" name="svauthorization:stMedDirTel" class="inputText" maxlength="15" size="15" title="phone number" readonly="readonly" /><label id="svauthorization:lbl_stMedDirTelExt" for="svauthorization:stMedDirTelExt" class="outputLabel"> <span id="svauthorization:lbltxt_stMedDirTelExt" class="outputText qLabel"> Ext: </span></label><input id="svauthorization:stMedDirTelExt" type="text" name="svauthorization:stMedDirTelExt" class="inputText4EM" maxlength="5" size="5" title="phone number extension" readonly="readonly" /><input id="svauthorization:stMedDirTelTty" type="checkbox" name="svauthorization:stMedDirTelTty" class="selectBooleanCheckbox" style="vertical-align: middle;" disabled="disabled" /><label id="svauthorization:lbl_stMedDirTelTty" for="svauthorization:stMedDirTelTty" class="outputLabel"> <span id="svauthorization:txt_lbl_stMedDirTelTty" class="outputText qLabel"> TTY</span></label> </p> </div> </div> <div class="rowContact"> <div class="leftColFixed100 qLabel"> <label id="svauthorization:lbl_stMedDirFax" for="svauthorization:stMedDirFax" class="outputLabel"> <span id="svauthorization:lbltxt_stMedDirFax" class="outputText">Fax:</span></label> </div> <div class="rightCol80"> <p></p> <p> <input id="svauthorization:stMedDirFax" type="text" name="svauthorization:stMedDirFax" class="inputText" maxlength="15" size="15" title="Fax number" readonly="readonly" /> </p> </div> </div> <div class="rowContact"> <div class="leftColFixed100 qLabel"> <label id="svauthorization:lbl_stMedDirEmail" for="svauthorization:stMedDirEmail" class="outputLabel"> <span id="svauthorization:txt_lbl_stMedDirEmail" class="outputText">E-mail:</span></label> </div> <div class="rightCol80"> <p></p> <input id="svauthorization:stMedDirEmail" type="text" name="svauthorization:stMedDirEmail" class="inputTextLong" readonly="readonly" /> </div> </div> </div> <H2 id="pageTitle">Attachments</H2> <div class="paragraph"> <span id="svattachment1:txt_tranPlan" class="outputText">Attachment #1: Transition Plan</span> </div> <div class="paragraph"> <div class="pph"> <span id="svattachment1:txt_tranPlanchkboxes" class="outputTextNB">Check the box next to any of the following changes from the current approved waiver. Check all boxes that apply.</span> </div> <div class="checkboxGroup"> <input id="svattachment1:tranPlanChgType1" type="checkbox" name="svattachment1:tranPlanChgType1" class="selectBooleanCheckbox" disabled="disabled" /><label id="svattachment1:lbl_ltranPlanChgType1" for="svattachment1:tranPlanChgType1" class="outputLabel"> <span id="svattachment1:txtlbl_tranPlanChgType1" class="outputText">Replacing an approved waiver with this waiver.</span></label> </div> <div class="checkboxGroup"> <input id="svattachment1:tranPlanChgType2" type="checkbox" name="svattachment1:tranPlanChgType2" class="selectBooleanCheckbox" disabled="disabled" /><label id="svattachment1:lbl_ltranPlanChgType2" for="svattachment1:tranPlanChgType2" class="outputLabel"> <span id="svattachment1:txtlbl_tranPlanChgType2" class="outputText">Combining waivers.</span></label> </div> <div class="checkboxGroup"> <input id="svattachment1:tranPlanChgType3" type="checkbox" name="svattachment1:tranPlanChgType3" class="selectBooleanCheckbox" disabled="disabled" /><label id="svattachment1:lbl_ltranPlanChgType3" for="svattachment1:tranPlanChgType3" class="outputLabel"> <span id="svattachment1:txtlbl_tranPlanChgType3" class="outputText">Splitting one waiver into two waivers.</span></label> </div> <div class="checkboxGroup"> <input id="svattachment1:tranPlanChgType4" type="checkbox" name="svattachment1:tranPlanChgType4" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svattachment1:lbl_ltranPlanChgType4" for="svattachment1:tranPlanChgType4" class="outputLabel"> <span id="svattachment1:txtlbl_tranPlanChgType4" class="outputText">Eliminating a service.</span></label> </div> <div class="checkboxGroup"> <input id="svattachment1:tranPlanChgType5" type="checkbox" name="svattachment1:tranPlanChgType5" class="selectBooleanCheckbox" disabled="disabled" /><label id="svattachment1:lbl_ltranPlanChgType5" for="svattachment1:tranPlanChgType5" class="outputLabel"> <span id="svattachment1:txtlbl_tranPlanChgType5" class="outputText">Adding or decreasing an individual cost limit pertaining to eligibility.</span></label> </div> <div class="checkboxGroup"> <input id="svattachment1:tranPlanChgType6" type="checkbox" name="svattachment1:tranPlanChgType6" class="selectBooleanCheckbox" disabled="disabled" /><label id="svattachment1:lbl_ltranPlanChgType6" for="svattachment1:tranPlanChgType6" class="outputLabel"> <span id="svattachment1:txtlbl_tranPlanChgType6" class="outputText">Adding or decreasing limits to a service or a set of services, as specified in Appendix C.</span></label> </div> <div class="checkboxGroup"> <input id="svattachment1:tranPlanChgType7" type="checkbox" name="svattachment1:tranPlanChgType7" class="selectBooleanCheckbox" disabled="disabled" /><label id="svattachment1:lbl_ltranPlanChgType7" for="svattachment1:tranPlanChgType7" class="outputLabel"> <span id="svattachment1:txtlbl_tranPlanChgType7" class="outputText">Reducing the unduplicated count of participants (Factor C).</span></label> </div> <div class="checkboxGroup"> <input id="svattachment1:tranPlanChgType8" type="checkbox" name="svattachment1:tranPlanChgType8" class="selectBooleanCheckbox" disabled="disabled" /><label id="svattachment1:lbl_ltranPlanChgType8" for="svattachment1:tranPlanChgType8" class="outputLabel"> <span id="svattachment1:txtlbl_tranPlanChgType8" class="outputText">Adding new, or decreasing, a limitation on the number of participants served at any point in time.</span></label> </div> <div class="checkboxGroup"> <input id="svattachment1:tranPlanChgType9" type="checkbox" name="svattachment1:tranPlanChgType9" class="selectBooleanCheckbox" disabled="disabled" /><label id="svattachment1:lbl_ltranPlanChgType9" for="svattachment1:tranPlanChgType9" class="outputLabel"> <span id="svattachment1:txtlbl_tranPlanChgType9" class="outputText">Making any changes that could result in some participants losing eligibility or being transferred to another waiver under 1915(c) or another Medicaid authority.</span></label> </div> <div class="checkboxGroup"> <input id="svattachment1:tranPlanChgType10" type="checkbox" name="svattachment1:tranPlanChgType10" class="selectBooleanCheckbox" disabled="disabled" /><label id="svattachment1:lbl_ltranPlanChgType10" for="svattachment1:tranPlanChgType10" class="outputLabel"> <span id="svattachment1:txtlbl_tranPlanChgType10" class="outputText">Making any changes that could result in reduced services to participants.</span></label> </div> </div> <p class="outputTextNB"> <label id="svattachment1:lbl_tranPlan" for="svattachment1:tranPlan" class="outputLabel"> <span id="svattachment1:txt_lbl_tranPlan" class="outputTextNB">Specify the transition plan for the waiver:</span></label> </p> <p> </p> <div class="chrCntDiv"> <label id="svattachment1:tranPlanChrCntLbl" for="svattachment1:tranPlanChrCnt" class="outputLabel"> <span id="svattachment1:tranPlanChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svattachment1:tranPlanChrCnt" type="text" name="svattachment1:tranPlanChrCnt" class="chrCnt" size="6" /><span id="svattachment1:tranPlanChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svattachment1:panel_tranPlan"><textarea id="svattachment1:tranPlan" name="svattachment1:tranPlan" class="inputTextareaLong" onkeyup="Count(this);" readonly="readonly">The PCA and PERS services are being eliminated from the waiver but concurrently being offered under the Medicaid state plan 1915k option. It is not anticipated that this will result in a reduction of services. It is anticipated that the payment source for the PCA services will become effective with the approval of CFC so that the state would be immediately able to collect the enhanced match under the 1915k. No changes would be made to the service plan without a face to face discussion with the waiver participant. Participants will be notified of the change in writing within 30 days once CMS approves the CFC. With the notification of the change, participants will be provided written information on how to request a Fair Hearing despite the fact that the department would not be taking any negative actions toward the client. We anticipate no impact on the providers as the neither the FI nor the payroll process will change.</textarea></span> </div> <br> <div class="outputTextNB"> <label id="svattachment1:lbl_hcbSetgsTransPlan" for="svattachment1:hcbSetgsTransPlan" class="outputLabel"> <span id="svattachment1:txt_lbl_hcbSetgsTransPlan" class="outputText">Attachment #2: Home and Community-Based Settings Waiver Transition Plan</span></label> </div> <div class="paragraph"> <span class="outputTextNB"> Specify the state's process to bring this waiver into compliance with federal home and community-based (HCB) settings requirements at 42 CFR 441.301(c)(4)-(5), and associated CMS guidance. </span> </div> <div class="paragraph"> <span class="outputTextNB em"> Consult with CMS for instructions before completing this item. This field describes the status of a transition process at the point in time of submission. Relevant information in the planning phase will differ from information required to describe attainment of milestones. </span> </div> <div class="paragraph"> <span class="outputTextNB em"> To the extent that the state has submitted a statewide HCB settings transition plan to CMS, the description in this field may reference that statewide plan. The narrative in this field must include enough information to demonstrate that this waiver complies with federal HCB settings requirements, including the compliance and transition requirements at 42 CFR 441.301(c)(6), and that this submission is consistent with the portions of the statewide HCB settings transition plan that are germane to this waiver. Quote or summarize germane portions of the statewide HCB settings transition plan as required. </span> </div> <div class="paragraph"> <span class="outputTextNB em"> Note that Appendix C-5 <u>HCB Settings</u> describes settings that do not require transition; the settings listed there meet federal HCB setting requirements as of the date of submission. Do not duplicate that information here. </span> </div> <div class="paragraph"> <span class="outputTextNB em"> Update this field and Appendix C-5 when submitting a renewal or amendment to this waiver for other purposes. It is not necessary for the state to amend the waiver solely for the purpose of updating this field and Appendix C-5. At the end of the state's HCB settings transition process for this waiver, when all waiver settings meet federal HCB setting requirements, enter "Completed" in this field, and include in Section C-5 the information on all HCB settings in the waiver. </span> </div> <p></P> <div class="chrCntDiv"> <label id="svattachment1:hcbSetgsTransPlanChrCntLbl" for="svattachment1:hcbSetgsTransPlanChrCnt" class="outputLabel"> <span id="svattachment1:hcbSetgsTransPlanChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svattachment1:hcbSetgsTransPlanChrCnt" type="text" name="svattachment1:hcbSetgsTransPlanChrCnt" class="chrCnt" size="6" /><span id="svattachment1:hcbSetgsTransPlanChrCntMax" class="chrCnt"> out of 60000</span> </div> <div class="inputTextareaWA"> <span id="svattachment1:panel_hcbSetgsTransPlan"><textarea id="svattachment1:hcbSetgsTransPlan" name="svattachment1:hcbSetgsTransPlan" class="inputTextareaLong" onkeyup="Count(this);" readonly="readonly">The state has reviewed the settings in which Personal Care Assistance Waiver participants reside. The state has determined that all participants reside in settings that are fully compliant with the new federal regulations. The services provided under this waiver are also provided in settings that meet the CMS settings requirements. Every waiver participant is assessed in their home environment by a department social worker. Based on that assessment, the department had concluded that the residential and nonresidential settings in this waiver, fully comport with the CMS requirements and the setting: - is integrated in and supports full access to the greater community - is selected by the individual - ensures an individual's right to privacy, dignity, respect and freedom from coercion and restraint - optimizes individual initiative, autonomy and independence - facilitates individual choice regarding services and supports and who provides them. The state will include settings language in its program regulations by 12/31/15 but, in the interim, as new participants are added to the program, the care manager doing the initial assessment will verify both by direct observation as well as by the person-centered assessment questions that the setting meets the requirements specified above. Public notice was posted in the CT Law Journal that included the transition plan. A 30 day comment period was provided. In addition, the transition plan was posted on the DSS web site and a 30 day comment period was included in the document. No additional comments were received. The state assures that the settings transition plan included with this waiver amendment will be subject to any provisions or requirements included in the State's approved Statewide Transition Plan. The State will implement any required changes upon approval of the Statewide Transition Plan and will make conforming changes to its waiver when it submits the next amendment or renewal.</textarea></span> </div> <H2 id="pageTitle">Additional Needed Information (Optional)</H2> <div class="outputTextNB"> <label id="svattachment2:lbl_tranPlan" for="svattachment2:optAddInfo" class="outputLabel"> <span id="svattachment2:txt_lbl_optAddInfo" class="outputTextNB">Provide additional needed information for the waiver (optional):</span></label> </div> <p></P> <div class="chrCntDiv"> <label id="svattachment2:optAddInfoChrCntLbl" for="svattachment2:optAddInfoChrCnt" class="outputLabel"> <span id="svattachment2:optAddInfoChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svattachment2:optAddInfoChrCnt" type="text" name="svattachment2:optAddInfoChrCnt" class="chrCnt" size="6" /><span id="svattachment2:optAddInfoChrCntMax" class="chrCnt"> out of 60000</span> </div> <div class="inputTextareaWA"> <span id="svattachment2:panel_optAddInfo"><textarea id="svattachment2:optAddInfo" name="svattachment2:optAddInfo" class="inputTextareaLong" onkeyup="Count(this);" readonly="readonly">PCA Waiver has always self-directed and does not coordinate living settings through vendors. Participants live in private residences or with family members. The addition of Adult Family Living as a service will necessitate coordination with provider networks to ensure this autonomous approach remains the manner in which services are implemented. No individuals on this waiver have received this service yet. Because the service is new and is initiated first through MFP as a demonstration project, managers of the PCA Waiver will stay in close communication with the MFP manager to ensure comportment with the new rules. Participants reside in private homes and may interact and conduct their daily routine as they see fit. The setting is chosen by the waiver participant as part of the person centered planning process. The participant has free choice of qualified providers for any other services provided in addition to the Adult Family Living Provider. The Department is in the process of assessing the credentialing language for this service against the requirements in the new CMS rule and will adjust the credentialing requirements to ensure compliance with regard to the settings characteristics specified in the new rule. This will be accomplished by 6/30/15. In the interim, as care managers doing person centered assessments for new waiver participants, they will be responsible to assess the setting's compliance with the required settings characteristics. Adult Family Living facilitates community integration for the participant and supports full access to the greater community. The setting is selected by the individual from among settings options. Adult Family Living ensures individuals' rights of privacy, dignity, respect and freedom from coercion, optimizes autonomy and independe4nce and facilitates choice regarding additional services. At each reassessment visit the care manager will assess the characteristics of the setting to ensure ongoing compliance with the final rules. The following language is from the DSS transition plan: Adult Family Living Upon further review DSS determined that Adult Family Living complies with the HCB settings requirements. Adult Family Living is provided in the home of the participant or of the caregiver. This service comports with CMS requirements as: &#8226; It is selected by the participant as part of the person centered planning process from a range of available services and qualified providers. &#8226; The participant understands that selecting this service setting also means he/she is selecting this service provider for services included in the bundled rate. &#8226; Additional home and community based services are selected by the participant from a range of qualified service providers to address additional needs identified in the person centered planning process. &#8226; New Language: This setting is for a maximum of three people. The rate for the service is a bundled rate, but the participant has free choice of qualified providers for any other HCBS provided in addition to Adult Family Living. Although DSS has concluded that this service is compliant with the HCB settings requirements, DSS will add language to its program regulations to specifically reflect the HCB settings requirements. Additionally, the department has met with the two current providers of Adult Family Living and reviewed the CMS final rules requirements regarding settings.</textarea></span> </div> <H2 id="pageTitle">Appendix A: Waiver Administration and Operation</H2> <OL class="numeric" id="A1"> <LI> <P class="outputTextNB"> <strong>State Line of Authority for Waiver Operation.</strong> Specify the state line of authority for the operation of the waiver (<em>select one</em>): </P> <div class="checkboxGroup"> <label><input id="svapdxA1_1:adminOpAgMed:0" type="radio" name="svapdxA1_1:adminOpAgMed" checked="checked" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;The waiver is operated by the State Medicaid agency.</label> </div> <div class="firstIndent"> <p class="outputTextNB"> Specify the Medicaid agency division/unit that has line authority for the operation of the waiver program <em>(select one)</em>: </p> <div class="checkboxGroup"><label><input id="svapdxA1_1:adminOpAgMAU:0" type="radio" name="svapdxA1_1:adminOpAgMAU" checked="checked" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;The Medical Assistance Unit.</label></div> <div class="firstIndent"> <p></p> <label id="svapdxA1_1:lbl_printAdminOpAgStMAU" for="svapdxA1_1:printAdminOpAgStMAU" class="outputLabel"> <span id="svapdxA1_1:txt_lbl_printAdminOpAgStMAU" class="outputTextNB">Specify the unit name:</span></label><span id="svapdxA1_1:panel_print_adminOpAgStMAU"><textarea id="svapdxA1_1:printAdminOpAgStMAU" name="svapdxA1_1:printAdminOpAgStMAU" class="inputTextarea" readonly="readonly">Alternate Care Unit/HCBS Unit</textarea></span> <span class="outputTextNB em"> (Do not complete item A-2)</span> </div> <div class="checkboxGroup"><label><input id="svapdxA1_1:adminOpAgMAU:1" type="radio" name="svapdxA1_1:adminOpAgMAU" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;Another division/unit within the State Medicaid agency that is separate from the Medical Assistance Unit.</label></div> <div class="firstIndent"> <p></p> <label id="svapdxA1_1:lbl_printAdminOpAgStNMAU" for="svapdxA1_1:printAdminOpAgStNMAU" class="outputLabel"> <span id="svapdxA1_1:txt_lbl_printAdminOpAgStNMAU" class="outputTextNB">Specify the division/unit name. This includes administrations/divisions under the umbrella agency that has been identified as the Single State Medicaid Agency.</span></label><span id="svapdxA1_1:panel_adminOpAgStNMAU"><textarea id="svapdxA1_1:printAdminOpAgStNMAU" name="svapdxA1_1:printAdminOpAgStNMAU" class="inputTextarea" readonly="readonly"></textarea></span> <span class="outputTextNB em"> (Complete item A-2-a).</span> </div> <div class="noShow"><label><input id="svapdxA1_1:adminOpAgMAU:2" type="radio" name="svapdxA1_1:adminOpAgMAU" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </div> <div class="checkboxGroup"><label><input id="svapdxA1_1:adminOpAgMed:1" type="radio" name="svapdxA1_1:adminOpAgMed" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;The waiver is operated by a separate agency of the State that is not a division/unit of the Medicaid agency.</label></div> <div class="firstIndent"> <p></p> <label id="svapdxA1_1:lbl_printAdminOpAgNonMed" for="svapdxA1_1:printAdminOpAgNonMed" class="outputLabel"> <span id="svapdxA1_1:txt_lbl_printAdminOpAgNonMed" class="outputTextNB">Specify the division/unit name:</span></label><span id="svapdxA1_1:panel_adminOpAgNonMed"><textarea id="svapdxA1_1:printAdminOpAgNonMed" name="svapdxA1_1:printAdminOpAgNonMed" class="inputTextarea" readonly="readonly"></textarea></span> <p class="outputTextNB"> In accordance with 42 CFR §431.10, the Medicaid agency exercises administrative discretion in the administration and supervision of the waiver and issues policies, rules and regulations related to the waiver. The interagency agreement or memorandum of understanding that sets forth the authority and arrangements for this policy is available through the Medicaid agency to CMS upon request. <em>(Complete item A-2-b).</em></p> </div> <div class="noShow"><label><input id="svapdxA1_1:adminOpAgMed:2" type="radio" name="svapdxA1_1:adminOpAgMed" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </LI> </OL> <H2 id="pageTitle">Appendix A: Waiver Administration and Operation</H2> <ol class="numeric" id="A1" start="2"> <li> <p><span id="svapdxA2_1:txt_Oversite" class="outputText">Oversight of Performance.</span></p> <ol class="alphaLC" id="A1a" start="1"> <li class="pph"> <div class="outputTextNB"> <strong>Medicaid Director Oversight of Performance When the Waiver is Operated by another Division/Unit within the State Medicaid Agency. </strong> <label id="svapdxA2_1:lbl_adminOvrstMethInt" for="svapdxA2_1:adminOvrstMethInt" class="outputLabel"> <span id="svapdxA2_1:txt_lbl_adminOvrstMethInt" class="outputTextNB">When the waiver is operated by another division/administration within the umbrella agency designated as the Single State Medicaid Agency. Specify (a) the functions performed by that division/administration (i.e., the Developmental Disabilities Administration within the Single State Medicaid Agency), (b) the document utilized to outline the roles and responsibilities related to waiver operation, and (c) the methods that are employed by the designated State Medicaid Director (in some instances, the head of umbrella agency) in the oversight of these activities:</span></label> </div> <span id="svapdxA2_1:txt_NotNeeded_adminOvrstMethInt" class="outputText">As indicated in section 1 of this appendix, the waiver is not operated by another division/unit within the State Medicaid agency. Thus this section does not need to be completed.</span> <div></div> <div class="chrCntDiv"> <label id="svapdxA2_1:adminOvrstMethIntChrCntLbl" for="svapdxA2_1:adminOvrstMethIntChrCnt" class="outputLabel"> <span id="svapdxA2_1:adminOvrstMethIntChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxA2_1:adminOvrstMethIntChrCnt" type="text" name="svapdxA2_1:adminOvrstMethIntChrCnt" class="chrCnt" size="6" /><span id="svapdxA2_1:adminOvrstMethIntChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxA2_1:panel_adminOvrstMethInt"><textarea id="svapdxA2_1:adminOvrstMethInt" name="svapdxA2_1:adminOvrstMethInt" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </li> <li class="pph"> <div class="outputTextNB"> <strong>Medicaid Agency Oversight of Operating Agency Performance. </strong> <label id="svapdxA2_1:lbl_adminOvrstMeth" for="svapdxA2_1:adminOvrstMeth" class="outputLabel"> <span id="svapdxA2_1:txt_lbl_adminOvrstMeth" class="outputTextNB">When the waiver is not operated by the Medicaid agency, specify the functions that are expressly delegated through a memorandum of understanding (MOU) or other written document, and indicate the frequency of review and update for that document. Specify the methods that the Medicaid agency uses to ensure that the operating agency performs its assigned waiver operational and administrative functions in accordance with waiver requirements. Also specify the frequency of Medicaid agency assessment of operating agency performance:</span></label> </div> <span id="svapdxA2_1:txt_NotNeeded" class="outputText">As indicated in section 1 of this appendix, the waiver is not operated by a separate agency of the State. Thus this section does not need to be completed.</span> <div></div> <div class="chrCntDiv"> <label id="svapdxA2_1:adminOvrstMethChrCntLbl" for="svapdxA2_1:adminOvrstMethChrCnt" class="outputLabel"> <span id="svapdxA2_1:adminOvrstMethChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxA2_1:adminOvrstMethChrCnt" type="text" name="svapdxA2_1:adminOvrstMethChrCnt" class="chrCnt" size="6" /><span id="svapdxA2_1:adminOvrstMethChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxA2_1:panel_adminOvrstMeth"><textarea id="svapdxA2_1:adminOvrstMeth" name="svapdxA2_1:adminOvrstMeth" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </li> </ol> </li> </ol> <H2 id="pageTitle">Appendix A: Waiver Administration and Operation</H2> <ol class="numeric" id="A1" start="3"> <li> <div class="outputTextNB"> <strong>Use of Contracted Entities.</strong> Specify whether contracted entities perform waiver operational and administrative functions on behalf of the Medicaid agency and/or the operating agency (if applicable) (<em>select one</em>): </div> <div class="checkboxGroup"><label><input id="svapdxA3_1:adminContrEnt:0" type="radio" name="svapdxA3_1:adminContrEnt" checked="checked" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;Yes. Contracted entities perform waiver operational and administrative functions on behalf of the Medicaid agency and/or operating agency (if applicable).</label></div> <div class="firstIndent"> <div class="outputTextNB"> <label id="svapdxA3_1:lbl_adminContrEntYDscr" for="svapdxA3_1:adminContrEntYDscr" class="outputLabel"> <span id="svapdxA3_1:txt_lbl_adminContrEntYDscr1" class="outputTextNB">Specify the types of contracted entities and briefly describe the functions that they perform.</span><span id="svapdxA3_1:txt_lbl_adminContrEntYDscr2" class="outputTextNB em"> Complete Items A-5 and A-6.:</span></label> </div> <div></div> <div class="chrCntDiv"> <label id="svapdxA3_1:adminContrEntYDscrChrCntLbl" for="svapdxA3_1:adminContrEntYDscrChrCnt" class="outputLabel"> <span id="svapdxA3_1:adminContrEntYDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxA3_1:adminContrEntYDscrChrCnt" type="text" name="svapdxA3_1:adminContrEntYDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxA3_1:adminContrEntYDscrChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxA3_1:panel_adminContrEntYDscr"><textarea id="svapdxA3_1:adminContrEntYDscr" name="svapdxA3_1:adminContrEntYDscr" class="inputTextarea15" onkeyup="Count(this);" readonly="readonly">The Connecticut Department of Social Services has contracted with a fiscal intermediary to maintain the payment records on services received and billed under the PCA waiver. The fiscal intermediary ensures that all billed services are within a consumer's Plan of Care and submits appropriate claims to the MMIS. This vendor also provides training and quality assurance functions, as detailed in Appendix H. The department contracts with Access Agencies as defined in CGS 17b-342(b). The Access Agency is required to hire appropriate staff to perform assessment and reassessment functions. The case managers conduct the initial assessment of the client for the purpose of developing a comprehensive plan of care and confirming the level of care determination that has been made by Department staff. Once the initial plan is developed, department approval of the plan is required. From that point forward, the Access Agency can modify plans as long as the plan remains within the nursing home cost cap. The Access Agency performs a supervisory level review of service plans. The Access Agencies have extensive quality assurance and quality improvement plans in place. The plans are presented to the Department for review at the time the contract is awarded.</textarea></span> </div> </div> <div class="checkboxGroup"><label><input id="svapdxA3_1:adminContrEnt:1" type="radio" name="svapdxA3_1:adminContrEnt" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;No. Contracted entities do not perform waiver operational and administrative functions on behalf of the Medicaid agency and/or the operating agency (if applicable).</label></div> <div class="noShow"><label><input id="svapdxA3_1:adminContrEnt:2" type="radio" name="svapdxA3_1:adminContrEnt" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </li> </ol> <H2 id="pageTitle">Appendix A: Waiver Administration and Operation</H2> <OL class="numeric" id="A1" start="4"> <LI> <P class="outputTextNB"><STRONG>Role of Local/Regional Non-State Entities.</STRONG> Indicate whether local or regional non-state entities perform waiver operational and administrative functions and, if so, specify the type of entity (<EM>Select One</EM>):</P> <div class="noShow"><label><input id="svapdxA4_1:adminNSE:2" type="radio" name="svapdxA4_1:adminNSE" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> <div class="checkboxGroup"> <label><input id="svapdxA4_1:adminNSE:1" type="radio" name="svapdxA4_1:adminNSE" checked="checked" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;Not applicable</label> </div> <div class="checkboxGroup"> <label><input id="svapdxA4_1:adminNSE:0" type="radio" name="svapdxA4_1:adminNSE" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;Applicable</label><span id="svapdxA4_1:txt_lbl_adminNSE0" class="outputTextNB"> - Local/regional non-state agencies perform waiver operational and administrative functions.</span> </div> <div class="firstIndent"> <div class="outputTextNB">Check each that applies:</div> <div class="checkboxGroup"> <input id="svapdxA4_1:adminNSEAgrm" type="checkbox" name="svapdxA4_1:adminNSEAgrm" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxA4_1:lbl_adminNSEAgrm" for="svapdxA4_1:adminNSEAgrm" class="outputLabel"> <span id="svapdxA4_1:txt_lbl_adminNSEAgrm1" class="outputText">Local/Regional non-state public agencies</span><span id="svapdxA4_1:txt_lbl_adminNSEAgrm2" class="outputTextNB"> perform waiver operational and administrative functions at the local or regional level. There is an </span><span id="svapdxA4_1:txt_lbl_adminNSEAgrm3" class="outputText"> interagency agreement or memorandum of understanding</span><span id="svapdxA4_1:txt_lbl_adminNSEAgrm4" class="outputTextNB"> between the State and these agencies that sets forth responsibilities and performance requirements for these agencies that is available through the Medicaid agency.</span></label> </div> <div class="firstIndent"> <p> <label id="svapdxA4_1:lbl_adminNSEAgType" for="svapdxA4_1:adminNSEAgType" class="outputLabel"> <span id="svapdxA4_1:txt_lbl_adminNSEAgType" class="outputTextNB em">Specify the nature of these agencies and complete items A-5 and A-6:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxA4_1:adminNSEAgTypeChrCntLbl" for="svapdxA4_1:adminNSEAgTypeChrCnt" class="outputLabel"> <span id="svapdxA4_1:adminNSEAgTypeChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxA4_1:adminNSEAgTypeChrCnt" type="text" name="svapdxA4_1:adminNSEAgTypeChrCnt" class="chrCnt" size="6" /><span id="svapdxA4_1:adminNSEAgTypeChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxA4_1:panel_adminNSEAgType"><textarea id="svapdxA4_1:adminNSEAgType" name="svapdxA4_1:adminNSEAgType" class="inputTextarea15" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="checkboxGroup"> <input id="svapdxA4_1:adminNSEContr" type="checkbox" name="svapdxA4_1:adminNSEContr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxA4_1:lbl_adminNSEContr" for="svapdxA4_1:adminNSEContr" class="outputLabel"> <span id="svapdxA4_1:txt_lbl_adminNSEContr1" class="outputText">Local/Regional non-governmental non-state entities</span><span id="svapdxA4_1:txt_lbl_adminNSEContr2" class="outputTextNB"> conduct waiver operational and administrative functions at the local or regional level. There is a contract between the Medicaid agency and/or the operating agency (when authorized by the Medicaid agency) and each local/regional non-state entity that sets forth the responsibilities and performance requirements of the local/regional entity. The </span><span id="svapdxA4_1:txt_lbl_adminNSEContr3" class="outputText">contract(s)</span><span id="svapdxA4_1:txt_lbl_adminNSEContr4" class="outputTextNB"> under which private entities conduct waiver operational functions are available to CMS upon request through the Medicaid agency or the operating agency (if applicable).</span></label> </div> <div class="firstIndent"> <p> <label id="svapdxA4_1:lbl_adminNSEConType" for="svapdxA4_1:adminNSEConType" class="outputLabel"> <span id="svapdxA4_1:txt_lbl_adminNSEConType" class="outputTextNB em">Specify the nature of these entities and complete items A-5 and A-6:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxA4_1:adminNSEConTypeChrCntLbl" for="svapdxA4_1:adminNSEConTypeChrCnt" class="outputLabel"> <span id="svapdxA4_1:adminNSEConTypeChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxA4_1:adminNSEConTypeChrCnt" type="text" name="svapdxA4_1:adminNSEConTypeChrCnt" class="chrCnt" size="6" /><span id="svapdxA4_1:adminNSEConTypeChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxA4_1:panel_adminNSEConType"><textarea id="svapdxA4_1:adminNSEConType" name="svapdxA4_1:adminNSEConType" class="inputTextarea15" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="noShow"> <input id="svapdxA4_1:adminNSEna" type="checkbox" name="svapdxA4_1:adminNSEna" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxA4_1:lbl_adminNSEna" for="svapdxA4_1:adminNSEna" class="outputLabel"> <span id="svapdxA4_1:txt_lbl_adminNSEna1" class="outputText">Not applicable</span><span id="svapdxA4_1:txt_lbl_adminNSEna2" class="outputTextNB"> - Local/regional non-state agencies do not perform waiver operational and administrative functions.</span></label> </div> </div> </LI> </OL> <H2 id="pageTitle">Appendix A: Waiver Administration and Operation</H2> <ol class="numeric" id="A1" start="5"> <li> <div> <span class="outputText">Responsibility for Assessment of Performance of Contracted and/or Local/Regional Non-State Entities.</span> <label id="svapdxA5_1:lbl_adminNSEPerfAg" for="svapdxA5_1:adminNSEPerfAg" class="outputLabel"> <span id="svapdxA5_1:txt_lbl_adminNSEPerfAg" class="outputTextNB">Specify the state agency or agencies responsible for assessing the performance of contracted and/or local/regional non-state entities in conducting waiver operational and administrative functions:</span></label> </div> <div></div> <div class="chrCntDiv"> <label id="svapdxA5_1:adminNSEPerfAgChrCntLbl" for="svapdxA5_1:adminNSEPerfAgChrCnt" class="outputLabel"> <span id="svapdxA5_1:adminNSEPerfAgChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxA5_1:adminNSEPerfAgChrCnt" type="text" name="svapdxA5_1:adminNSEPerfAgChrCnt" class="chrCnt" size="6" /><span id="svapdxA5_1:adminNSEPerfAgChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxA5_1:panel_adminNSEPerfAg"><textarea id="svapdxA5_1:adminNSEPerfAg" name="svapdxA5_1:adminNSEPerfAg" class="inputTextarea15" onkeyup="Count(this);" readonly="readonly">The Department of Social Services Alternate Care Unit/HCBS Unit is responsible for overseeing the contractual operations of the Access Agencies. This is done through on site administrative reviews as well as clinical record reviews, client and provider visits and consumer satisfaction surveys. Monitoring of reporting requirements takes place on a monthly basis. The Department's Division of Quality Assurance also conducts regular audits to ensure the Access Agencies' compliance with billing and claims submission. The state also monitors the fiscal intermediary via reports and on site audits by the Department's quality assurance division. The Department also oversees the contract for the fiscal intermediary and oversees all of the functions performed by the contracted entity. Both the Access Agency and fiscal intermediary contracts were awarded as a result of a competitive procurement.</textarea></span> </div> </li> </ol> <H2 id="pageTitle">Appendix A: Waiver Administration and Operation</H2> <ol class="numeric" id="A1" start="6"> <li> <div> <span class="outputText">Assessment Methods and Frequency. </span> <label id="svapdxA6_1:lbl_adminNSEPerfMth" for="svapdxA6_1:adminNSEPerfMth" class="outputLabel"> <span id="svapdxA6_1:txt_lbl_adminNSEPerfMth" class="outputTextNB">Describe the methods that are used to assess the performance of contracted and/or local/regional non-state entities to ensure that they perform assigned waiver operational and administrative functions in accordance with waiver requirements. Also specify how frequently the performance of contracted and/or local/regional non-state entities is assessed:</span></label> </div> <div></div> <div class="chrCntDiv"> <label id="svapdxA6_1:adminNSEPerfMthChrCntLbl" for="svapdxA6_1:adminNSEPerfMthChrCnt" class="outputLabel"> <span id="svapdxA6_1:adminNSEPerfMthChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxA6_1:adminNSEPerfMthChrCnt" type="text" name="svapdxA6_1:adminNSEPerfMthChrCnt" class="chrCnt" size="6" /><span id="svapdxA6_1:adminNSEPerfMthChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxA6_1:panel_adminNSEPerfMth"><textarea id="svapdxA6_1:adminNSEPerfMth" name="svapdxA6_1:adminNSEPerfMth" class="inputTextareaLong" onkeyup="Count(this);" readonly="readonly">1. Quarterly and ad hoc reports 2. Annual on-site visits to review operational and administrative functions 3. Annual survey of waiver participants for consumer input on program needs as well as the performance of the fiscal intermediary. 4. Ongoing correspondence between the fiscal intermediary and DSS staff regarding progress on deliverables (e.g. claims processing, training schedules, number of eligible providers, etc.) 5. On site audits of Access Agencies no less frequently than every 18 months.</textarea></span> </div> </li> </ol> <H2 id="pageTitle">Appendix A: Waiver Administration and Operation</H2> <ol class="numeric" id="A1" start="7"> <li> <div class="paragraph"> <span class="otuputText">Distribution of Waiver Operational and Administrative Functions.</span> <span class="outputTextNB">In the following table, specify the entity or entities that have responsibility for conducting each of the waiver operational and administrative functions listed (<em>check each that applies</em>):</span> </div> <div class="paragraph"> <span class="outputTextNB">In accordance with 42 CFR §431.10, when the Medicaid agency does not directly conduct a function, it supervises the performance of the function and establishes and/or approves policies that affect the function.</span> <span class="outputTextNB">All functions not performed directly by the Medicaid agency must be delegated in writing and monitored by the Medicaid Agency. </span> <span class="outputTextNB em"> Note: More than one box may be checked per item. Ensure that Medicaid is checked when the Single State Medicaid Agency (1) conducts the function directly; (2) supervises the delegated function; and/or (3) establishes and/or approves policies related to the function.</span> </div> <table id="svapdxA7_1:adminFunc" class="ckboxTable" border="1" cellpadding="1" cellspacing="0" summary="Specify the entity or entities that have responsibility for conducting each of the waiver operational and administrative functions (check each that applies)" ><thead ><tr ><th scope="col" ><span class="outputText">Function</span></th><th scope="col" ><span class="outputText">Medicaid Agency</span></th><th scope="col" ><span class="outputText">Contracted Entity</span></th></tr> </thead><tbody > <tr ><td class="lft" ><input id="svapdxA7_1:adminFunc:0:rowID" type="text" name="svapdxA7_1:adminFunc:0:rowID" value="200900" class="noShow" disabled="disabled" readonly="readonly" /><span id="svapdxA7_1:adminFunc:0:tafcNameLabel" class="lft">Participant waiver enrollment</span></td> <td class="ctr" ><input id="svapdxA7_1:adminFunc:0:cbtafcMedAg" type="checkbox" name="svapdxA7_1:adminFunc:0:cbtafcMedAg" checked="checked" class="selectBooleanCheckbox ctr" disabled="disabled" /></td> <td class="ctr" ><input id="svapdxA7_1:adminFunc:0:cbtafcContr" type="checkbox" name="svapdxA7_1:adminFunc:0:cbtafcContr" checked="checked" class="selectBooleanCheckbox ctr" disabled="disabled" /></td> </tr> <tr ><td class="lft" ><input id="svapdxA7_1:adminFunc:1:rowID" type="text" name="svapdxA7_1:adminFunc:1:rowID" value="200870" class="noShow" disabled="disabled" readonly="readonly" /><span id="svapdxA7_1:adminFunc:1:tafcNameLabel" class="lft">Waiver enrollment managed against approved limits</span></td> <td class="ctr" ><input id="svapdxA7_1:adminFunc:1:cbtafcMedAg" type="checkbox" name="svapdxA7_1:adminFunc:1:cbtafcMedAg" checked="checked" class="selectBooleanCheckbox ctr" disabled="disabled" /></td> <td class="ctr" ><input id="svapdxA7_1:adminFunc:1:cbtafcContr" type="checkbox" name="svapdxA7_1:adminFunc:1:cbtafcContr" class="selectBooleanCheckbox ctr" disabled="disabled" /></td> </tr> <tr ><td class="lft" ><input id="svapdxA7_1:adminFunc:2:rowID" type="text" name="svapdxA7_1:adminFunc:2:rowID" value="200857" class="noShow" disabled="disabled" readonly="readonly" /><span id="svapdxA7_1:adminFunc:2:tafcNameLabel" class="lft">Waiver expenditures managed against approved levels</span></td> <td class="ctr" ><input id="svapdxA7_1:adminFunc:2:cbtafcMedAg" type="checkbox" name="svapdxA7_1:adminFunc:2:cbtafcMedAg" checked="checked" class="selectBooleanCheckbox ctr" disabled="disabled" /></td> <td class="ctr" ><input id="svapdxA7_1:adminFunc:2:cbtafcContr" type="checkbox" name="svapdxA7_1:adminFunc:2:cbtafcContr" checked="checked" class="selectBooleanCheckbox ctr" disabled="disabled" /></td> </tr> <tr ><td class="lft" ><input id="svapdxA7_1:adminFunc:3:rowID" type="text" name="svapdxA7_1:adminFunc:3:rowID" value="200861" class="noShow" disabled="disabled" readonly="readonly" /><span id="svapdxA7_1:adminFunc:3:tafcNameLabel" class="lft">Level of care evaluation</span></td> <td class="ctr" ><input id="svapdxA7_1:adminFunc:3:cbtafcMedAg" type="checkbox" name="svapdxA7_1:adminFunc:3:cbtafcMedAg" checked="checked" class="selectBooleanCheckbox ctr" disabled="disabled" /></td> <td class="ctr" ><input id="svapdxA7_1:adminFunc:3:cbtafcContr" type="checkbox" name="svapdxA7_1:adminFunc:3:cbtafcContr" checked="checked" class="selectBooleanCheckbox ctr" disabled="disabled" /></td> </tr> <tr ><td class="lft" ><input id="svapdxA7_1:adminFunc:4:rowID" type="text" name="svapdxA7_1:adminFunc:4:rowID" value="200877" class="noShow" disabled="disabled" readonly="readonly" /><span id="svapdxA7_1:adminFunc:4:tafcNameLabel" class="lft">Review of Participant service plans</span></td> <td class="ctr" ><input id="svapdxA7_1:adminFunc:4:cbtafcMedAg" type="checkbox" name="svapdxA7_1:adminFunc:4:cbtafcMedAg" checked="checked" class="selectBooleanCheckbox ctr" disabled="disabled" /></td> <td class="ctr" ><input id="svapdxA7_1:adminFunc:4:cbtafcContr" type="checkbox" name="svapdxA7_1:adminFunc:4:cbtafcContr" checked="checked" class="selectBooleanCheckbox ctr" disabled="disabled" /></td> </tr> <tr ><td class="lft" ><input id="svapdxA7_1:adminFunc:5:rowID" type="text" name="svapdxA7_1:adminFunc:5:rowID" value="200848" class="noShow" disabled="disabled" readonly="readonly" /><span id="svapdxA7_1:adminFunc:5:tafcNameLabel" class="lft">Prior authorization of waiver services</span></td> <td class="ctr" ><input id="svapdxA7_1:adminFunc:5:cbtafcMedAg" type="checkbox" name="svapdxA7_1:adminFunc:5:cbtafcMedAg" checked="checked" class="selectBooleanCheckbox ctr" disabled="disabled" /></td> <td class="ctr" ><input id="svapdxA7_1:adminFunc:5:cbtafcContr" type="checkbox" name="svapdxA7_1:adminFunc:5:cbtafcContr" checked="checked" class="selectBooleanCheckbox ctr" disabled="disabled" /></td> </tr> <tr ><td class="lft" ><input id="svapdxA7_1:adminFunc:6:rowID" type="text" name="svapdxA7_1:adminFunc:6:rowID" value="200851" class="noShow" disabled="disabled" readonly="readonly" /><span id="svapdxA7_1:adminFunc:6:tafcNameLabel" class="lft">Utilization management</span></td> <td class="ctr" ><input id="svapdxA7_1:adminFunc:6:cbtafcMedAg" type="checkbox" name="svapdxA7_1:adminFunc:6:cbtafcMedAg" checked="checked" class="selectBooleanCheckbox ctr" disabled="disabled" /></td> <td class="ctr" ><input id="svapdxA7_1:adminFunc:6:cbtafcContr" type="checkbox" name="svapdxA7_1:adminFunc:6:cbtafcContr" checked="checked" class="selectBooleanCheckbox ctr" disabled="disabled" /></td> </tr> <tr ><td class="lft" ><input id="svapdxA7_1:adminFunc:7:rowID" type="text" name="svapdxA7_1:adminFunc:7:rowID" value="200847" class="noShow" disabled="disabled" readonly="readonly" /><span id="svapdxA7_1:adminFunc:7:tafcNameLabel" class="lft">Qualified provider enrollment</span></td> <td class="ctr" ><input id="svapdxA7_1:adminFunc:7:cbtafcMedAg" type="checkbox" name="svapdxA7_1:adminFunc:7:cbtafcMedAg" checked="checked" class="selectBooleanCheckbox ctr" disabled="disabled" /></td> <td class="ctr" ><input id="svapdxA7_1:adminFunc:7:cbtafcContr" type="checkbox" name="svapdxA7_1:adminFunc:7:cbtafcContr" checked="checked" class="selectBooleanCheckbox ctr" disabled="disabled" /></td> </tr> <tr ><td class="lft" ><input id="svapdxA7_1:adminFunc:8:rowID" type="text" name="svapdxA7_1:adminFunc:8:rowID" value="200852" class="noShow" disabled="disabled" readonly="readonly" /><span id="svapdxA7_1:adminFunc:8:tafcNameLabel" class="lft">Execution of Medicaid provider agreements</span></td> <td class="ctr" ><input id="svapdxA7_1:adminFunc:8:cbtafcMedAg" type="checkbox" name="svapdxA7_1:adminFunc:8:cbtafcMedAg" checked="checked" class="selectBooleanCheckbox ctr" disabled="disabled" /></td> <td class="ctr" ><input id="svapdxA7_1:adminFunc:8:cbtafcContr" type="checkbox" name="svapdxA7_1:adminFunc:8:cbtafcContr" checked="checked" class="selectBooleanCheckbox ctr" disabled="disabled" /></td> </tr> <tr ><td class="lft" ><input id="svapdxA7_1:adminFunc:9:rowID" type="text" name="svapdxA7_1:adminFunc:9:rowID" value="200901" class="noShow" disabled="disabled" readonly="readonly" /><span id="svapdxA7_1:adminFunc:9:tafcNameLabel" class="lft">Establishment of a statewide rate methodology</span></td> <td class="ctr" ><input id="svapdxA7_1:adminFunc:9:cbtafcMedAg" type="checkbox" name="svapdxA7_1:adminFunc:9:cbtafcMedAg" checked="checked" class="selectBooleanCheckbox ctr" disabled="disabled" /></td> <td class="ctr" ><input id="svapdxA7_1:adminFunc:9:cbtafcContr" type="checkbox" name="svapdxA7_1:adminFunc:9:cbtafcContr" class="selectBooleanCheckbox ctr" disabled="disabled" /></td> </tr> <tr ><td class="lft" ><input id="svapdxA7_1:adminFunc:10:rowID" type="text" name="svapdxA7_1:adminFunc:10:rowID" value="200878" class="noShow" disabled="disabled" readonly="readonly" /><span id="svapdxA7_1:adminFunc:10:tafcNameLabel" class="lft">Rules, policies, procedures and information development governing the waiver program</span></td> <td class="ctr" ><input id="svapdxA7_1:adminFunc:10:cbtafcMedAg" type="checkbox" name="svapdxA7_1:adminFunc:10:cbtafcMedAg" checked="checked" class="selectBooleanCheckbox ctr" disabled="disabled" /></td> <td class="ctr" ><input id="svapdxA7_1:adminFunc:10:cbtafcContr" type="checkbox" name="svapdxA7_1:adminFunc:10:cbtafcContr" class="selectBooleanCheckbox ctr" disabled="disabled" /></td> </tr> <tr ><td class="lft" ><input id="svapdxA7_1:adminFunc:11:rowID" type="text" name="svapdxA7_1:adminFunc:11:rowID" value="200895" class="noShow" disabled="disabled" readonly="readonly" /><span id="svapdxA7_1:adminFunc:11:tafcNameLabel" class="lft">Quality assurance and quality improvement activities</span></td> <td class="ctr" ><input id="svapdxA7_1:adminFunc:11:cbtafcMedAg" type="checkbox" name="svapdxA7_1:adminFunc:11:cbtafcMedAg" checked="checked" class="selectBooleanCheckbox ctr" disabled="disabled" /></td> <td class="ctr" ><input id="svapdxA7_1:adminFunc:11:cbtafcContr" type="checkbox" name="svapdxA7_1:adminFunc:11:cbtafcContr" checked="checked" class="selectBooleanCheckbox ctr" disabled="disabled" /></td> </tr> </tbody> </table> </li> </ol> <H2 id="pageTitle">Appendix A: Waiver Administration and Operation</H2> <H3 id="pageSubTitle">Quality Improvement: Administrative Authority of the Single State Medicaid Agency</H3> <div class="paragraph"> <span class="outputTextNB em"> As a distinct component of the State’s quality improvement strategy, provide information in the following fields to detail the State’s methods for discovery and remediation. </span> </div> <ol class="alphaLC" id="AQa" start="1" > <li style="margin-top: 1em;"> <div class="paragraph"> <span class="outputText">Methods for Discovery: Administrative Authority</span> </div> <div class="paragraph em"> <span class="outputText">The Medicaid Agency retains ultimate administrative authority and responsibility for the operation of the waiver program by exercising oversight of the performance of waiver functions by other state and local/regional non-state agencies (if appropriate) and contracted entities.</span> </div> <ol class="romanLC" id="AQai" start="1"> <li> <!-- a.i. --> <div> <p> <span class="outputText">Performance Measures</span> </p> <div class="pph"> <span class="outputText em">For each performance measure the State will use to assess compliance with the statutory assurance, complete the following. Performance measures for administrative authority should not duplicate measures found in other appendices of the waiver application.</span> <span class="outputTextNB em"> As necessary and applicable, performance measures should focus on:</span> <ul> <li class="outputTextNB">Uniformity of development/execution of provider agreements throughout all geographic areas covered by the waiver</li> <li class="outputTextNB">Equitable distribution of waiver openings in all geographic areas covered by the waiver</li> <li class="outputTextNB">Compliance with HCB settings requirements and other new regulatory components (for waiver actions submitted on or after March 17, 2014)</li> </ul> <p style="padding-left:1.5em;"> <span class="outputText em">Where possible, include numerator/denominator.</span> </p> </div> <p class="pph"> <span class="outputTextNB em ul">For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.</span> </p> </div> <div class=""> <table id="svapdxAQ_1:dtPMPrnt" class="nstTableX" summary="Expanded dynamic table for services" ><tbody > <tr ><td > <div style="padding-bottom: 1.5em; width:90%;" > <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:pmName" class="inputTextPct">Number and percent of new waiver provider's recurited, who will meet licensure/certification standards prior to delivery of services. Numerator = number of new waiver providers recruited who will meet licensure/certification standards prior to delivery of services. Denominator = total number of new waiver providers recruited.</span> </div> </div> <table id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource" style="width: 90%" class="nstTableX" border="0" cellpadding="2" cellspacing="0" summary="dynamic table for Performance Measure Data Sources" ><tbody > <tr ><td ><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Record reviews, on-site</span><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct"></span></div></div></div><table id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:pmPnlGrdChkboxSet" class="nstTableX" border="1" cellpadding="3" cellspacing="0" style="vertical-align: top; margin-bottom: 1.5em;"> <tbody> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsRpSma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsSaPct" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaLtPct" class="outputText">Less than 100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="inputTextarea" readonly="readonly">Fiscal intermediary</textarea></span></div></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsFdCo" checked="checked" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsSaOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:0:dssa6"></span></td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <div style="padding: 1em 0 1em 0;"> </div> <div> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:pmDAA" class="outputText" style="margin-top: 1.5em;">Data Aggregation and Analysis:</span> </div> <table id="pmPnlGrdChkboxSet" class="nstTableX" id="pmPnlGrdChkboxSet"cellpadding="3" cellspacing="0" border="1" style="vertical-align: top; width: 85%;"> <THEAD><tr align="left" valign="top"> <th id="rp" class="third"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:txtPMfom2" class="outputTextNB em">(check each that applies):</span> </th> </tr></THEAD> <TBODY valign="top" align="left"> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:pmDaRpSma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:pmDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:pmDaFdQu" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:pmDaRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:pmDaRpOthDsc" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:pmDaRpOthDsc" class="inputTextarea" readonly="readonly">Fiscal Intermediary</textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:pmDaFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:txtlbl_pmDaFdAn" class="outputText">Annually</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:pmDaFdCo" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:txtlblpmDaFdCo" class="outputText">Continuously and Ongoing</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup" > <input id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:pmDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:pmDaFdOtDsc" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:pmDaFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> </tr> </TBODY> </table> <div> </div> </td> </tr> <tr ><td > <div style="padding-bottom: 1.5em; width:90%;" > <span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:pmName" class="inputTextPct">Number and Percent of new waiver providers who complete their required training prior to delivery of services. Numerator = number of new waiver providers who received training prior to service delivery. Denominator = the total number of providers trained.</span> </div> </div> <table id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource" style="width: 90%" class="nstTableX" border="0" cellpadding="2" cellspacing="0" summary="dynamic table for Performance Measure Data Sources" ><tbody > <tr ><td ><label id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Training verification records</span><div id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct"></span></div></div></div><table id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:pmPnlGrdChkboxSet" class="nstTableX" border="1" cellpadding="3" cellspacing="0" style="vertical-align: top; margin-bottom: 1.5em;"> <tbody> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsRpSma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsSaPct" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaLtPct" class="outputText">Less than 100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsFdQu" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="inputTextarea" readonly="readonly">Fiscal intermediary</textarea></span></div></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsFdCo" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsSaOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:dtDataSource:0:dssa6"></span></td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <div style="padding: 1em 0 1em 0;"> </div> <div> <span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:pmDAA" class="outputText" style="margin-top: 1.5em;">Data Aggregation and Analysis:</span> </div> <table id="pmPnlGrdChkboxSet" class="nstTableX" id="pmPnlGrdChkboxSet"cellpadding="3" cellspacing="0" border="1" style="vertical-align: top; width: 85%;"> <THEAD><tr align="left" valign="top"> <th id="rp" class="third"> <span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:txtPMfom2" class="outputTextNB em">(check each that applies):</span> </th> </tr></THEAD> <TBODY valign="top" align="left"> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:pmDaRpSma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:pmDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:pmDaFdQu" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:pmDaRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:pmDaRpOthDsc" name="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:pmDaRpOthDsc" class="inputTextarea" readonly="readonly">Fiscal Intermediary</textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:pmDaFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:txtlbl_pmDaFdAn" class="outputText">Annually</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:pmDaFdCo" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:txtlblpmDaFdCo" class="outputText">Continuously and Ongoing</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup" > <input id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:pmDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:pmDaFdOtDsc" name="svapdxAQ_1:dtPMPrnt:1:svQmPerfMeas:pmDaFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> </tr> </TBODY> </table> <div> </div> </td> </tr> <tr ><td > <div style="padding-bottom: 1.5em; width:90%;" > <span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:pmName" class="inputTextPct">Number and Percent of claims paid in accordance with the participant's authorized services. Numerator = authorized claims payments. Demominator = total numbers of payments.</span> </div> </div> <table id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource" style="width: 90%" class="nstTableX" border="0" cellpadding="2" cellspacing="0" summary="dynamic table for Performance Measure Data Sources" ><tbody > <tr ><td ><label id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Other</span><div id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct">Time sheets compared to service plans, claims remittance advices</span></div></div></div><table id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:pmPnlGrdChkboxSet" class="nstTableX" border="1" cellpadding="3" cellspacing="0" style="vertical-align: top; margin-bottom: 1.5em;"> <tbody> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsRpSma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsFdWk" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsSaPct" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaLtPct" class="outputText">Less than 100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="inputTextarea" readonly="readonly">Fiscal intermediary</textarea></span></div></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsFdCo" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsSaOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:dtDataSource:0:dssa6"></span></td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <div style="padding: 1em 0 1em 0;"> </div> <div> <span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:pmDAA" class="outputText" style="margin-top: 1.5em;">Data Aggregation and Analysis:</span> </div> <table id="pmPnlGrdChkboxSet" class="nstTableX" id="pmPnlGrdChkboxSet"cellpadding="3" cellspacing="0" border="1" style="vertical-align: top; width: 85%;"> <THEAD><tr align="left" valign="top"> <th id="rp" class="third"> <span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:txtPMfom2" class="outputTextNB em">(check each that applies):</span> </th> </tr></THEAD> <TBODY valign="top" align="left"> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:pmDaRpSma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:pmDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:pmDaFdQu" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:pmDaRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:pmDaRpOthDsc" name="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:pmDaRpOthDsc" class="inputTextarea" readonly="readonly">Fiscal Intermediary</textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:pmDaFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:txtlbl_pmDaFdAn" class="outputText">Annually</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:pmDaFdCo" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:txtlblpmDaFdCo" class="outputText">Continuously and Ongoing</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup" > <input id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:pmDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:pmDaFdOtDsc" name="svapdxAQ_1:dtPMPrnt:2:svQmPerfMeas:pmDaFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> </tr> </TBODY> </table> <div> </div> </td> </tr> <tr ><td > <div style="padding-bottom: 1.5em; width:90%;" > <span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:pmName" class="inputTextPct">Number and Percent of monitoring reports received from the fiscal intermediary that is on time as specified in their contract. Numerator = monitoring reports received from the fiscal intermediary as specified in their contract. Denominator = total number of reports received.</span> </div> </div> <table id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource" style="width: 90%" class="nstTableX" border="0" cellpadding="2" cellspacing="0" summary="dynamic table for Performance Measure Data Sources" ><tbody > <tr ><td ><label id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Reports to State Medicaid Agency on delegated Administrative functions</span><div id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct"></span></div></div></div><table id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:pmPnlGrdChkboxSet" class="nstTableX" border="1" cellpadding="3" cellspacing="0" style="vertical-align: top; margin-bottom: 1.5em;"> <tbody> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsRpSma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsSaPct" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaLtPct" class="outputText">Less than 100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsFdQu" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="inputTextarea" readonly="readonly">Fiscal intermediary</textarea></span></div></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsFdAn" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsFdCo" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsSaOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:dtDataSource:0:dssa6"></span></td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <div style="padding: 1em 0 1em 0;"> </div> <div> <span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:pmDAA" class="outputText" style="margin-top: 1.5em;">Data Aggregation and Analysis:</span> </div> <table id="pmPnlGrdChkboxSet" class="nstTableX" id="pmPnlGrdChkboxSet"cellpadding="3" cellspacing="0" border="1" style="vertical-align: top; width: 85%;"> <THEAD><tr align="left" valign="top"> <th id="rp" class="third"> <span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:txtPMfom2" class="outputTextNB em">(check each that applies):</span> </th> </tr></THEAD> <TBODY valign="top" align="left"> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:pmDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:pmDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:pmDaFdQu" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:pmDaRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:pmDaRpOthDsc" name="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:pmDaRpOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:pmDaFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:txtlbl_pmDaFdAn" class="outputText">Annually</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:pmDaFdCo" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:txtlblpmDaFdCo" class="outputText">Continuously and Ongoing</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup" > <input id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:pmDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:pmDaFdOtDsc" name="svapdxAQ_1:dtPMPrnt:3:svQmPerfMeas:pmDaFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> </tr> </TBODY> </table> <div> </div> </td> </tr> <tr ><td > <div style="padding-bottom: 1.5em; width:90%;" > <span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:pmName" class="inputTextPct">Number and Percent of quarterly and/or annual on-site visits to review operational and functions of the fiscal intermediary. Numerator = annual on-site visits to review operational and functions of the fiscal intermediary. Denominator = the total number of on-site visits.</span> </div> </div> <table id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource" style="width: 90%" class="nstTableX" border="0" cellpadding="2" cellspacing="0" summary="dynamic table for Performance Measure Data Sources" ><tbody > <tr ><td ><label id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Record reviews, on-site</span><div id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct"></span></div></div></div><table id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:pmPnlGrdChkboxSet" class="nstTableX" border="1" cellpadding="3" cellspacing="0" style="vertical-align: top; margin-bottom: 1.5em;"> <tbody> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsSaPct" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaLtPct" class="outputText">Less than 100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsFdQu" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsFdAn" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsFdCo" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsSaOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:dtDataSource:0:dssa6"></span></td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <div style="padding: 1em 0 1em 0;"> </div> <div> <span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:pmDAA" class="outputText" style="margin-top: 1.5em;">Data Aggregation and Analysis:</span> </div> <table id="pmPnlGrdChkboxSet" class="nstTableX" id="pmPnlGrdChkboxSet"cellpadding="3" cellspacing="0" border="1" style="vertical-align: top; width: 85%;"> <THEAD><tr align="left" valign="top"> <th id="rp" class="third"> <span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:txtPMfom2" class="outputTextNB em">(check each that applies):</span> </th> </tr></THEAD> <TBODY valign="top" align="left"> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:pmDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:pmDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:pmDaFdQu" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:pmDaRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:pmDaRpOthDsc" name="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:pmDaRpOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:pmDaFdAn" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:txtlbl_pmDaFdAn" class="outputText">Annually</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:pmDaFdCo" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:txtlblpmDaFdCo" class="outputText">Continuously and Ongoing</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup" > <input id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:pmDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:pmDaFdOtDsc" name="svapdxAQ_1:dtPMPrnt:4:svQmPerfMeas:pmDaFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> </tr> </TBODY> </table> <div> </div> </td> </tr> <tr ><td > <div style="padding-bottom: 1.5em; width:90%;" > <span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:pmName" class="inputTextPct">Number and Percent of participants and/or legal guardian who receive information about how to report abuse, neglect, and exploitation. Numerator = participants and/or legal guardian who received information about how to report abuse, neglect, and exploitation. Denominator - total number of participants recieved.</span> </div> </div> <table id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource" style="width: 90%" class="nstTableX" border="0" cellpadding="2" cellspacing="0" summary="dynamic table for Performance Measure Data Sources" ><tbody > <tr ><td ><label id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Record reviews, on-site</span><div id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct"></span></div></div></div><table id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:pmPnlGrdChkboxSet" class="nstTableX" border="1" cellpadding="3" cellspacing="0" style="vertical-align: top; margin-bottom: 1.5em;"> <tbody> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsSaPct" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaLtPct" class="outputText">Less than 100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsFdCo" checked="checked" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsSaOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:dtDataSource:0:dssa6"></span></td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <div style="padding: 1em 0 1em 0;"> </div> <div> <span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:pmDAA" class="outputText" style="margin-top: 1.5em;">Data Aggregation and Analysis:</span> </div> <table id="pmPnlGrdChkboxSet" class="nstTableX" id="pmPnlGrdChkboxSet"cellpadding="3" cellspacing="0" border="1" style="vertical-align: top; width: 85%;"> <THEAD><tr align="left" valign="top"> <th id="rp" class="third"> <span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:txtPMfom2" class="outputTextNB em">(check each that applies):</span> </th> </tr></THEAD> <TBODY valign="top" align="left"> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:pmDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:pmDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:pmDaFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:pmDaRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:pmDaRpOthDsc" name="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:pmDaRpOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:pmDaFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:txtlbl_pmDaFdAn" class="outputText">Annually</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:pmDaFdCo" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:txtlblpmDaFdCo" class="outputText">Continuously and Ongoing</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup" > <input id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:pmDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:pmDaFdOtDsc" name="svapdxAQ_1:dtPMPrnt:5:svQmPerfMeas:pmDaFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> </tr> </TBODY> </table> <div> </div> </td> </tr> </tbody> </table> </div> </li> <li style="padding-top: 1.5em;"> <!-- a.ii. --> <div class="paragraph"> <label id="svapdxAQ_1:lbl_qmAaDiscDesc" for="svapdxAQ_1:qmAaDiscDesc" class="outputLabel"> <span id="svapdxAQ_1:txt_lbl_qmAaDiscDesc" class="outputTextNB">If applicable, in the textbox below provide any necessary additional information on the strategies employed by the State to discover/identify problems/issues within the waiver program, including frequency and parties responsible.</span></label> </div> <div></div> <div class="chrCntDiv"> <label id="svapdxAQ_1:qmAaDiscDescChrCntLbl" for="svapdxAQ_1:qmAaDiscDescChrCnt" class="outputLabel"> <span id="svapdxAQ_1:qmAaDiscDescChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxAQ_1:qmAaDiscDescChrCnt" type="text" name="svapdxAQ_1:qmAaDiscDescChrCnt" class="chrCnt" size="6" /><span id="svapdxAQ_1:qmAaDiscDescChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxAQ_1:panel_qmAaDiscDesc"><textarea id="svapdxAQ_1:qmAaDiscDesc" name="svapdxAQ_1:qmAaDiscDesc" class="inputTextarea" onkeyup="Count(this);" readonly="readonly">The Alternate Care Unit Manager has ongoing correspondence with the fiscal intermediary and Access Agency including an every other week conference call to proactively address any issues or potential issues.</textarea></span> </div> </li> </ol> </li> <li style="margin-top: 1em;"> <!-- b. --> <div class="paragraph"> <span class="outputText">Methods for Remediation/Fixing Individual Problems</span> </div> <ol class="romanLC" id="AQb" start="1"> <li> <!-- b.i. --> <div class="paragraph"> <label id="svapdxAQ_1:lbl_qmAaRemDesc" for="svapdxAQ_1:qmAaRemDesc" class="outputLabel"> <span id="svapdxAQ_1:txt_lbl_qmAaRemDesc" class="outputTextNB">Describe the State’s method for addressing individual problems as they are discovered. Include information regarding responsible parties and GENERAL methods for problem correction. In addition, provide information on the methods used by the State to document these items. </span></label> </div> <div></div> <div class="chrCntDiv"> <label id="svapdxAQ_1:qmAaRemDescChrCntLbl" for="svapdxAQ_1:qmAaRemDescChrCnt" class="outputLabel"> <span id="svapdxAQ_1:qmAaRemDescChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxAQ_1:qmAaRemDescChrCnt" type="text" name="svapdxAQ_1:qmAaRemDescChrCnt" class="chrCnt" size="6" /><span id="svapdxAQ_1:qmAaRemDescChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxAQ_1:panel_qmAaRemDesc"><textarea id="svapdxAQ_1:qmAaRemDesc" name="svapdxAQ_1:qmAaRemDesc" class="inputTextarea" onkeyup="Count(this);" readonly="readonly">Central Office staff, who is assigned oversight of the contract with the fiscal intermediary is the point person for all problems that may occur. The staff member would hear and assess the problem, contact any person or department that needs to address the problem and then follow up to assure that there was resolution.</textarea></span> </div> </li> <li> <!-- b.ii. --> <div class="paragraph"> <span id="svapdxAQ_1:txt1">Remediation Data Aggregation</span> </div> <div> <span id="svapdxAQ_1:txt2">Remediation-related Data Aggregation and Analysis (including trend identification)</span> <table cellpadding="3" cellspacing="0" border="1" class="nstTableX" style="width: 85%;"> <thead align="left"> <tr> <th id="rp" style="width:42%;"> <span id="svapdxAQ_1:txtrp">Responsible Party</span><span id="svapdxAQ_1:txtrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" style="width:42%;"> <span id="svapdxAQ_1:txtfom">Frequency of data aggregation and analysis</span><span id="svapdxAQ_1:txtfom2" class="outputTextNB em">(check each that applies):</span> </th> </tr> </thead> <tbody align="left" valign="top"> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxAQ_1:qmAaDaRpSma" type="checkbox" name="svapdxAQ_1:qmAaDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:lbl_qmAaDaRpSma" for="svapdxAQ_1:qmAaDaRpSma" class="outputLabel"> <span id="svapdxAQ_1:txtlbl_qmAaDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxAQ_1:qmAaDaFdWk" type="checkbox" name="svapdxAQ_1:qmAaDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:lbl_qmAaDaFdWk" for="svapdxAQ_1:qmAaDaFdWk" class="outputLabel"> <span id="svapdxAQ_1:txtlbl_qmAaDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxAQ_1:qmAaDaRpOpa" type="checkbox" name="svapdxAQ_1:qmAaDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:lbl_qmAaDaRpOpa" for="svapdxAQ_1:qmAaDaRpOpa" class="outputLabel"> <span id="svapdxAQ_1:txtlbl_qmAaDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxAQ_1:qmAaDaFdMo" type="checkbox" name="svapdxAQ_1:qmAaDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:lbl_qmAaDaFdMo" for="svapdxAQ_1:qmAaDaFdMo" class="outputLabel"> <span id="svapdxAQ_1:txtlbl_qmAaDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxAQ_1:qmAaDaRpCma" type="checkbox" name="svapdxAQ_1:qmAaDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:lbl_qmAaDaRpCma" for="svapdxAQ_1:qmAaDaRpCma" class="outputLabel"> <span id="svapdxAQ_1:txtlbl_qmAaDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxAQ_1:qmAaDaFdQu" type="checkbox" name="svapdxAQ_1:qmAaDaFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:lbl_qmAaDaFdQu" for="svapdxAQ_1:qmAaDaFdQu" class="outputLabel"> <span id="svapdxAQ_1:txtlbl_qmAaDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxAQ_1:qmAaDaRpOth" type="checkbox" name="svapdxAQ_1:qmAaDaRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:lbl_qmAaDaRpOth" for="svapdxAQ_1:qmAaDaRpOth" class="outputLabel"> <span id="svapdxAQ_1:txtlbl_qmAaDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxAQ_1:lbl2_qmAaDaRpOthDsc" for="svapdxAQ_1:qmAaDaRpOthDsc" class="outputLabel"> <span id="svapdxAQ_1:txtlbl2_qmAaDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxAQ_1:panel_qmAaDaRpOthDsc"><textarea id="svapdxAQ_1:qmAaDaRpOthDsc" name="svapdxAQ_1:qmAaDaRpOthDsc" class="inputTextarea" readonly="readonly"></textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxAQ_1:qmAaDaFdAn" type="checkbox" name="svapdxAQ_1:qmAaDaFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:lbl_qmAaDaFdAn" for="svapdxAQ_1:qmAaDaFdAn" class="outputLabel"> <span id="svapdxAQ_1:txtlbl_qmAaDaFdAn" class="outputText">Annually</span></label> </div> </td> </tr> <tr> <td headers="rp"> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxAQ_1:qmAaDaFdCo" type="checkbox" name="svapdxAQ_1:qmAaDaFdCo" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxAQ_1:lbl_qmAaDaFdCo" for="svapdxAQ_1:qmAaDaFdCo" class="outputLabel"> <span id="svapdxAQ_1:txtlblqmAaDaFdCo" class="outputText">Continuously and Ongoing</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxAQ_1:qmAaDaFdOt" type="checkbox" name="svapdxAQ_1:qmAaDaFdOt" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxAQ_1:lbl_qmAaDaFdOt" for="svapdxAQ_1:qmAaDaFdOt" class="outputLabel"> <span id="svapdxAQ_1:txtlblqmAaDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxAQ_1:lbl2_qmAaDaFdOtDsc" for="svapdxAQ_1:qmAaDaFdOtDsc" class="outputLabel"> <span id="svapdxAQ_1:txtlbl2qmAaDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxAQ_1:panel_qmAaDaFdOtDsc"><textarea id="svapdxAQ_1:qmAaDaFdOtDsc" name="svapdxAQ_1:qmAaDaFdOtDsc" class="inputTextarea" readonly="readonly">As needed</textarea></span> </div> </div> </td> </tr> </tbody> </table> </div> </li> </ol> </li> <li style="margin-top: 1em;"> <!-- c. --> <div> <span class="outputText">Timelines</span> </div> <div> <label id="svapdxAQ_1:lbl_qmAaTimeLn" for="svapdxAQ_1:qmAaTimeLn" class="outputLabel"> <span id="svapdxAQ_1:txt_lbl_qmAaTimeLn" class="outputTextNB">When the State does not have all elements of the Quality Improvement Strategy in place, provide timelines to design methods for discovery and remediation related to the assurance of Administrative Authority that are currently non-operational.</span></label> <div> <div class="checkboxGroup"><label><input id="svapdxAQ_1:qmAaTimeLn:1" type="radio" name="svapdxAQ_1:qmAaTimeLn" checked="checked" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;No</label></div> <div class="checkboxGroup"><label><input id="svapdxAQ_1:qmAaTimeLn:0" type="radio" name="svapdxAQ_1:qmAaTimeLn" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;Yes</label></div> <div class="noShow"><label><input id="svapdxAQ_1:qmAaTimeLn:2" type="radio" name="svapdxAQ_1:qmAaTimeLn" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </div> </div> <div class="firstIndent"> <label id="svapdxAQ_1:lbl_qmAaTimeLnDsc" for="svapdxAQ_1:qmAaTimeLnDsc" class="outputLabel"> <span id="svapdxAQ_1:txt_lbl_qmAaTimeLnDsc" class="outputTextNB">Please provide a detailed strategy for assuring Administrative Authority, the specific timeline for implementing identified strategies, and the parties responsible for its operation.</span></label> <div></div> <div class="chrCntDiv"> <label id="svapdxAQ_1:qmAaTimeLnDscChrCntLbl" for="svapdxAQ_1:qmAaTimeLnDscChrCnt" class="outputLabel"> <span id="svapdxAQ_1:qmAaTimeLnDscChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxAQ_1:qmAaTimeLnDscChrCnt" type="text" name="svapdxAQ_1:qmAaTimeLnDscChrCnt" class="chrCnt" size="6" /><span id="svapdxAQ_1:qmAaTimeLnDscChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxAQ_1:panel_qualc"><textarea id="svapdxAQ_1:qmAaTimeLnDsc" name="svapdxAQ_1:qmAaTimeLnDsc" class="inputTextarea" readonly="readonly"></textarea></span> </div> </div> </li> </ol> <H2 id="pageTitle">Appendix B: Participant Access and Eligibility</H2> <H3 id="pageSubTitle">B-1: Specification of the Waiver Target Group(s)</H3> <OL class="alphaLC" start="1"> <LI> <DIV class="outputTextNB"> <STRONG>Target Group(s).</STRONG> Under the waiver of Section 1902(a)(10)(B) of the Act, the State limits waiver services to one or more groups or subgroups of individuals. Please see the instruction manual for specifics regarding age limits. <EM>In accordance with 42 CFR §441.301(b)(6), select one or more waiver target groups, check each of the subgroups in the selected target group(s) that may receive services under the waiver, and specify the minimum and maximum (if any) age of individuals served in each subgroup:</EM> </DIV> <DIV> <TABLE border="1" cellpadding="0" cellspacing="0" class="b1Table" title="Target Groups" summary="check each of the subgroups in the selected target group that may receive services under the waiver, and specify the minimum and maximum (if any) age of individuals served in each subgroup."> <THEAD> <TR> <TH rowspan="2" id="tg">Target Group</TH> <TH rowspan="2" id="incl">Included</TH> <TH rowspan="2" id="targ">Target SubGroup</TH> <TH rowspan="2" id="minAge">Minimum Age</TH> <TH colspan="2" id="maxAge">Maximum Age</TH> </TR> <TR> <TH id="thruAge">Maximum Age Limit</TH> <TH id="noMaxAge">No Maximum Age Limit</TH> </TR> </THEAD> <TBODY> <TR> <TD headers="tg" colspan="6" class="rowHL"> <div class="checkboxGroup"> <input id="svapdxB1_1:elgTrgGrpTgag" type="checkbox" name="svapdxB1_1:elgTrgGrpTgag" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxB1_1:lblelgTrgGrpTgag" for="svapdxB1_1:elgTrgGrpTgag" class="outputLabel"> <span id="svapdxB1_1:lbltxtelgTrgGrpTgag" class="outputText">Aged or Disabled, or Both - General</span></label> </div> </TD> </TR> <TR> <TD headers="tg"></TD> <TD headers="incl"> <input id="svapdxB1_1:tgagAgedInc" type="checkbox" name="svapdxB1_1:tgagAgedInc" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /> </TD> <TD headers="targ" class="desc">Aged</TD> <TD headers="minAge"> <input id="svapdxB1_1:tgagAgedMin" type="text" name="svapdxB1_1:tgagAgedMin" class="inputText" readonly="readonly" /> </TD> <TD headers="maxAge thruAge"> <input id="svapdxB1_1:tgagAgedMax" type="text" name="svapdxB1_1:tgagAgedMax" class="inputText" readonly="readonly" /> </TD> <TD headers="maxAge noMaxAge"> <input id="svapdxB1_1:tgagAgedNoMax" type="checkbox" name="svapdxB1_1:tgagAgedNoMax" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /> </TD> </TR> <TR> <TD headers="tg"></TD> <TD headers="incl"> <input id="svapdxB1_1:tgagDisPhyInc" type="checkbox" name="svapdxB1_1:tgagDisPhyInc" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /> </TD> <TD headers="targ" class="desc">Disabled (Physical)</TD> <TD headers="minAge"> <input id="svapdxB1_1:tgagDisPhyMin" type="text" name="svapdxB1_1:tgagDisPhyMin" value="18" class="inputText" readonly="readonly" /> </TD> <TD headers="maxAge thruAge"> <input id="svapdxB1_1:tgagDisPhyMax" type="text" name="svapdxB1_1:tgagDisPhyMax" value="64" class="inputText" readonly="readonly" /> </TD> <TD headers="maxAge noMaxAge">&nbsp;&nbsp;<span id="svapdxB1_1:tgagDisPhyNoMaxHolder"></span> </TD> </TR> <TR> <TD headers="tg"></TD> <TD headers="incl"> <input id="svapdxB1_1:tgagDisOthInc" type="checkbox" name="svapdxB1_1:tgagDisOthInc" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /> </TD> <TD headers="targ" class="desc">Disabled (Other)</TD> <TD headers="minAge"> <input id="svapdxB1_1:tgagDisOthMin" type="text" name="svapdxB1_1:tgagDisOthMin" class="inputText" readonly="readonly" /> </TD> <TD headers="maxAge thruAge"> <input id="svapdxB1_1:tgagDisOthMax" type="text" name="svapdxB1_1:tgagDisOthMax" class="inputText" readonly="readonly" /> </TD> <TD headers="maxAge noMaxAge">&nbsp;&nbsp;<span id="svapdxB1_1:tgagDisOthNoMaxHolder"></span></TD> </TR> <TR> <TD headers="tg" colspan="6" class="rowHL"> <div class="checkboxGroup"> <input id="svapdxB1_1:elgTrgGrpTgagsrs" type="checkbox" name="svapdxB1_1:elgTrgGrpTgagsrs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxB1_1:lblelgTrgGrpTgagsrs" for="svapdxB1_1:elgTrgGrpTgagsrs" class="outputLabel"> <span id="svapdxB1_1:lbltxtelgTrgGrpTgagsrs" class="outputText">Aged or Disabled, or Both - Specific Recognized Subgroups</span></label> </div> </TD> </TR> <TR> <TD headers="tg"></TD> <TD headers="incl"> <input id="svapdxB1_1:tgagBraInjInc" type="checkbox" name="svapdxB1_1:tgagBraInjInc" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /> </TD> <TD headers="targ" class="desc">Brain Injury</TD> <TD headers="minAge"> <input id="svapdxB1_1:tgagBraInjMin" type="text" name="svapdxB1_1:tgagBraInjMin" class="inputText" readonly="readonly" /> </TD> <TD headers="maxAge thruAge"> <input id="svapdxB1_1:tgagBraInjMax" type="text" name="svapdxB1_1:tgagBraInjMax" class="inputText" readonly="readonly" /> </TD> <TD headers="maxAge noMaxAge"> <input id="svapdxB1_1:tgagBraInjNoMax" type="checkbox" name="svapdxB1_1:tgagBraInjNoMax" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /> </TD> </TR> <TR> <TD headers="tg"></TD> <TD headers="incl"> <input id="svapdxB1_1:tgagHivAidsInc" type="checkbox" name="svapdxB1_1:tgagHivAidsInc" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /> </TD> <TD headers="targ" class="desc">HIV/AIDS</TD> <TD headers="minAge"> <input id="svapdxB1_1:tgagHivAidsMin" type="text" name="svapdxB1_1:tgagHivAidsMin" class="inputText" readonly="readonly" /> </TD> <TD headers="maxAge thruAge"> <input id="svapdxB1_1:tgagHivAidsMax" type="text" name="svapdxB1_1:tgagHivAidsMax" class="inputText" readonly="readonly" /> </TD> <TD headers="maxAge noMaxAge"> <input id="svapdxB1_1:tgagHivAidsNoMax" type="checkbox" name="svapdxB1_1:tgagHivAidsNoMax" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /> </TD> </TR> <TR> <TD headers="tg"></TD> <TD headers="incl"> <input id="svapdxB1_1:tgagMedFraInc" type="checkbox" name="svapdxB1_1:tgagMedFraInc" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /> </TD> <TD headers="targ" class="desc">Medically Fragile</TD> <TD headers="minAge"> <input id="svapdxB1_1:tgagMedFraMin" type="text" name="svapdxB1_1:tgagMedFraMin" class="inputText" readonly="readonly" /> </TD> <TD headers="maxAge thruAge"> <input id="svapdxB1_1:tgagMedFraMax" type="text" name="svapdxB1_1:tgagMedFraMax" class="inputText" readonly="readonly" /> </TD> <TD headers="maxAge noMaxAge"> <input id="svapdxB1_1:tgagMedFraNoMax" type="checkbox" name="svapdxB1_1:tgagMedFraNoMax" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /> </TD> </TR> <TR> <TD headers="tg"></TD> <TD headers="incl"> <input id="svapdxB1_1:tgagTecDepInc" type="checkbox" name="svapdxB1_1:tgagTecDepInc" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /> </TD> <TD headers="targ" class="desc">Technology Dependent</TD> <TD headers="minAge"> <input id="svapdxB1_1:tgagTecDepMin" type="text" name="svapdxB1_1:tgagTecDepMin" class="inputText" readonly="readonly" /> </TD> <TD headers="maxAge thruAge"> <input id="svapdxB1_1:tgagTecDepMax" type="text" name="svapdxB1_1:tgagTecDepMax" class="inputText" readonly="readonly" /> </TD> <TD headers="maxAge noMaxAge"> <input id="svapdxB1_1:tgagTecDepNoMax" type="checkbox" name="svapdxB1_1:tgagTecDepNoMax" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /> </TD> </TR> <TR> <TD headers="tg" colspan="6" class="rowHL" > <div class="checkboxGroup"> <input id="svapdxB1_1:elgTrgGrpTgdd" type="checkbox" name="svapdxB1_1:elgTrgGrpTgdd" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxB1_1:lblelgTrgGrpTgdd" for="svapdxB1_1:elgTrgGrpTgdd" class="outputLabel"> <span id="svapdxB1_1:lbltxtelgTrgGrpTgdd" class="outputText">Intellectual Disability or Developmental Disability, or Both</span></label> </div> </TD> </TR> <TR> <TD headers="tg"></TD> <TD headers="incl"> <input id="svapdxB1_1:tgddAutismInc" type="checkbox" name="svapdxB1_1:tgddAutismInc" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /> </TD> <TD headers="targ" class="desc">Autism</TD> <TD headers="minAge"> <input id="svapdxB1_1:tgddAutismMin" type="text" name="svapdxB1_1:tgddAutismMin" class="inputText" readonly="readonly" /> </TD> <TD headers="maxAge thruAge"> <input id="svapdxB1_1:tgddAutismMax" type="text" name="svapdxB1_1:tgddAutismMax" class="inputText" readonly="readonly" /> </TD> <TD headers="maxAge noMaxAge"> <input id="svapdxB1_1:tgddAutismNoMax" type="checkbox" name="svapdxB1_1:tgddAutismNoMax" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /> </TD> </TR> <TR> <TD headers="tg"></TD> <TD headers="incl"> <input id="svapdxB1_1:tgddDevDisInc" type="checkbox" name="svapdxB1_1:tgddDevDisInc" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /> </TD> <TD headers="targ" class="desc">Developmental Disability</TD> <TD headers="minAge"> <input id="svapdxB1_1:tgddDevDisMin" type="text" name="svapdxB1_1:tgddDevDisMin" class="inputText" readonly="readonly" /> </TD> <TD headers="maxAge thruAge"> <input id="svapdxB1_1:tgddDevDisMax" type="text" name="svapdxB1_1:tgddDevDisMax" class="inputText" readonly="readonly" /> </TD> <TD headers="maxAge noMaxAge"> <input id="svapdxB1_1:tgddDevDisNoMax" type="checkbox" name="svapdxB1_1:tgddDevDisNoMax" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /> </TD> </TR> <TR> <TD headers="tg"></TD> <TD headers="incl"> <input id="svapdxB1_1:tgddMenRetInc" type="checkbox" name="svapdxB1_1:tgddMenRetInc" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /> </TD> <TD headers="targ" class="desc">Intellectual Disability</TD> <TD headers="minAge"> <input id="svapdxB1_1:tgddMenRetMin" type="text" name="svapdxB1_1:tgddMenRetMin" class="inputText" readonly="readonly" /> </TD> <TD headers="maxAge thruAge"> <input id="svapdxB1_1:tgddMenRetMax" type="text" name="svapdxB1_1:tgddMenRetMax" class="inputText" readonly="readonly" /> </TD> <TD headers="maxAge noMaxAge"> <input id="svapdxB1_1:tgddMenRetNoMax" type="checkbox" name="svapdxB1_1:tgddMenRetNoMax" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /> </TD> </TR> <TR> <TD headers="tg" colspan="6" class="rowHL" > <div class="checkboxGroup"> <input id="svapdxB1_1:elgTrgGrpTgmi" type="checkbox" name="svapdxB1_1:elgTrgGrpTgmi" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxB1_1:lblelgTrgGrpTgmi" for="svapdxB1_1:elgTrgGrpTgmi" class="outputLabel"> <span id="svapdxB1_1:lbltxtelgTrgGrpTgmi" class="outputText">Mental Illness</span></label> </div> </TD> </TR> <TR> <TD headers="tg"></TD> <TD headers="incl"> <input id="svapdxB1_1:tgmiMIInc" type="checkbox" name="svapdxB1_1:tgmiMIInc" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /> </TD> <TD headers="targ" class="desc">Mental Illness</TD> <TD headers="minAge"> <input id="svapdxB1_1:tgmiMIMin" type="text" name="svapdxB1_1:tgmiMIMin" class="inputText" readonly="readonly" /> </TD> <TD headers="maxAge thruAge"> <input id="svapdxB1_1:tgmiMIMax" type="text" name="svapdxB1_1:tgmiMIMax" class="inputText" readonly="readonly" /> </TD> <TD headers="maxAge noMaxAge"> &nbsp;&nbsp; </TD> </TR> <TR> <TD headers="tg"></TD> <TD headers="incl"> <input id="svapdxB1_1:tgmiEmoDisInc" type="checkbox" name="svapdxB1_1:tgmiEmoDisInc" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /> </TD> <TD headers="targ" class="desc">Serious Emotional Disturbance</TD> <TD headers="minAge"> <input id="svapdxB1_1:tgmiEmoDisMin" type="text" name="svapdxB1_1:tgmiEmoDisMin" class="inputText" readonly="readonly" /> </TD> <TD headers="maxAge thruAge"> <input id="svapdxB1_1:tgmiEmoDisMax" type="text" name="svapdxB1_1:tgmiEmoDisMax" class="inputText" readonly="readonly" /> </TD> <TD headers="maxAge noMaxAge">&nbsp;&nbsp;<span id="svapdxB1_1:tgmiEmoDisNoMaxHolder"> </span></TD> </TR> <TR> <TD headers="tg" colspan="6" align="left"> <div class="noShow"> </div></TD> </TR> </TBODY> </TABLE> </DIV> </LI> <LI> <p class="outputTextNB"> <label id="svapdxB1_1:lblelgTrgAddCrit" for="svapdxB1_1:elgTrgAddCrit" class="outputLabel"> <span id="svapdxB1_1:lbltxtelgTrgAddCrit1" class="outputText">Additional Criteria. </span><span id="svapdxB1_1:lbltxtelgTrgAddCrit2" class="outputTextNB">The State further specifies its target group(s) as follows:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxB1_1:elgTrgAddCritChrCntLbl" for="svapdxB1_1:elgTrgAddCritChrCnt" class="outputLabel"> <span id="svapdxB1_1:elgTrgAddCritChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxB1_1:elgTrgAddCritChrCnt" type="text" name="svapdxB1_1:elgTrgAddCritChrCnt" class="chrCnt" size="6" /><span id="svapdxB1_1:elgTrgAddCritChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxB1_1:panel_elgTrgAddCrit"><textarea id="svapdxB1_1:elgTrgAddCrit" name="svapdxB1_1:elgTrgAddCrit" class="inputTextarea15" onkeyup="Count(this);" readonly="readonly">Participants must be ages 18-64 to participate on Personal Care Assistance Waiver and need physical assistance with at least two Activities of Daily Living who without these services would otherwise be institutionalized. This is a self-directed model of care. During the initial assessment phase, a re-determination or a requested level of service change, the case manager conducts a home visit. During this assessment, the self-direction process is explained to the client. The client, in collaboration with the social worker will decide if they are willing and able to self-direct and if not, who he/she would like to appoint as their representative. Participants must either have the cognitive capacity to understand the requirements of self direction or appoint someone to act on their behalf. The fiscal intermediary provides employer training and that presents an opportunity for participants to verbalize their understanding and willingness to continue with self direction.</textarea></span> </div> </LI> <LI> <p class="outputTextNB"> <label id="svapdxB1_1:lblelgTrgAgeTrns" for="svapdxB1_1:elgTrgAgeTrns" class="outputLabel"> <span id="svapdxB1_1:lbltxtelgTrgAgeTrns1" class="outputText">Transition of Individuals Affected by Maximum Age Limitation. </span><span id="svapdxB1_1:lbltxtelgTrgAgeTrns2" class="outputTextNB">When there is a maximum age limit that applies to individuals who may be served in the waiver, describe the transition planning procedures that are undertaken on behalf of participants affected by the age limit </span><span id="svapdxB1_1:lbltxtelgTrgAgeTrns3" class="outputTextNB em"> (select one):</span></label> </p> <table id="svapdxB1_1:elgTrgAgeTrns" class="selectOneRadio"> <tr> <td> <input type="radio" name="svapdxB1_1:elgTrgAgeTrns" id="svapdxB1_1:elgTrgAgeTrns:0" value="0" onclick="return callSave(this, event);" title="Transition of Individuals Affected by Maximum Age Limitation" disabled="disabled" /><label for="svapdxB1_1:elgTrgAgeTrns:0"> Not applicable. There is no maximum age limit</label></td> </tr> <tr> <td> <input type="radio" checked="checked" name="svapdxB1_1:elgTrgAgeTrns" id="svapdxB1_1:elgTrgAgeTrns:1" value="1" onclick="return callSave(this, event);" title="Transition of Individuals Affected by Maximum Age Limitation" disabled="disabled" /><label for="svapdxB1_1:elgTrgAgeTrns:1"> The following transition planning procedures are employed for participants who will reach the waiver's maximum age limit.</label></td> </tr> </table> <div class="firstIndent"> <p class="outputTextNB"> <label id="svapdxB1_1:lblelgTrgAgeTrnsDscr" for="svapdxB1_1:elgTrgAgeTrnsDscr" class="outputLabel"> <span id="svapdxB1_1:lbltxtelgTrgAgeTrnsDscr" class="outputTextNB em">Specify:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxB1_1:elgTrgAgeTrnsDscrChrCntLbl" for="svapdxB1_1:elgTrgAgeTrnsDscrChrCnt" class="outputLabel"> <span id="svapdxB1_1:elgTrgAgeTrnsDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxB1_1:elgTrgAgeTrnsDscrChrCnt" type="text" name="svapdxB1_1:elgTrgAgeTrnsDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxB1_1:elgTrgAgeTrnsDscrChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxB1_1:panel_elgTrgAgeTrnsDscr"><textarea id="svapdxB1_1:elgTrgAgeTrnsDscr" name="svapdxB1_1:elgTrgAgeTrnsDscr" class="inputTextarea15" onkeypress="Count(this);" readonly="readonly">PCA Waiver participants, who are age 64 and 6 months or older, shall be given a minimum of 60 days advance notice of the required program change. This notice will provide adequate information about the changes taking place so that participants and/or their legal representative will be able to make an informed choice of their service options (i.e., transition to the Connecticut Home Care Program for Elders, institutionalization, or state plan services). The State will ensure successful transition to the waiver program through the following activities: 1.Access Agency Care Manager will conduct a home visit with the waiver participant/representative. At this home visit, the care manager will do the following: a. alert the participant to the program change b. review options as noted above c. provide a letter detailing the program change and participant options d. provide a copy of the CHCPE Brochure e. have the participant/representative sign a release of information for the CHCPE program. 2. Participants will have 14 days from the date of the home visit to determine their service choice. They can do this in writing or call their DSS social worker to let them know. 3. If the participant/representative does not follow-up, Access Agency care managers will contact them to support their election. If these efforts to support affirmative selection are not successful, PCA Waiver participants will be automatically enrolled in the CHCPE Waiver and their services will remain the same.</textarea></span> </div> </div> </LI> </OL> <H2 id="pageTitle">Appendix B: Participant Access and Eligibility</H2> <H3 id="pageSubTitle">B-2: Individual Cost Limit <span id="pageNumber">(1 of 2)</span></H3> <OL class="alphaLC" start="1"> <LI> <div class="outputTextNB"> <STRONG>Individual Cost Limit.</STRONG> The following individual cost limit applies when determining whether to deny home and community-based services or entrance to the waiver to an otherwise eligible individual <em>(select one)</em>. Please note that a State may have only ONE individual cost limit for the purposes of determining eligibility for the waiver: </div> <!-- CHECKBOX 0 --> <div class="checkboxGroup"> <label><input id="svapdxB2_1:elgIclType:0" type="radio" name="svapdxB2_1:elgIclType" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;No Cost Limit.</label> <span class="outputTextNB">The State does not apply an individual cost limit. <em>Do not complete Item B-2-b or item B-2-c</em>.</span> </div> <!-- CHECKBOX 1 --> <div class="checkboxGroup"> <label><input id="svapdxB2_1:elgIclType:1" type="radio" name="svapdxB2_1:elgIclType" checked="checked" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;Cost Limit in Excess of Institutional Costs.</label> <span class="outputTextNB"> The State refuses entrance to the waiver to any otherwise eligible individual when the State reasonably expects that the cost of the home and community-based services furnished to that individual would exceed the cost of a level of care specified for the waiver up to an amount specified by the State. <em>Complete Items B-2-b and B-2-c</em>.</span> </div> <div class="firstIndent"> <p class="outputTextNB"><strong>The limit specified by the State is</strong> <em>(select one)</em></p> <!-- CHECKBOX 1 - 0 --> <div class="checkboxGroup"> <label><input id="svapdxB2_1:elgIclExcCstCalc:0" type="radio" name="svapdxB2_1:elgIclExcCstCalc" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;A level higher than 100% of the institutional average.</label> </div> <div class="firstIndent"> <p></p> <p> <label id="svapdxB2_1:lblelgIclExcCstPct" for="svapdxB2_1:elgIclExcCstPct" class="outputLabel"> <span id="svapdxB2_1:lbltxtelgIclExcCstPct" class="outputTextNB">Specify the percentage:</span></label><input id="svapdxB2_1:elgIclExcCstPct" type="text" name="svapdxB2_1:elgIclExcCstPct" class="inputTextSmall" readonly="readonly" /> </p> </div> <!-- CHECKBOX 1 - 1 --> <div class="checkboxGroup"> <label><input id="svapdxB2_1:elgIclExcCstCalc:1" type="radio" name="svapdxB2_1:elgIclExcCstCalc" checked="checked" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;Other</label> </div> <div class="firstIndent"> <p class="outputTextNB"> <label id="svapdxB2_1:lblelgIclExcCstFrml" for="svapdxB2_1:elgIclExcCstFrml" class="outputLabel"> <span id="svapdxB2_1:lbltxtelgIclExcCstFrml" class="outputTextNB em">Specify:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxB2_1:elgIclExcCstFrmlChrCntLbl" for="svapdxB2_1:elgIclExcCstFrmlChrCnt" class="outputLabel"> <span id="svapdxB2_1:elgIclExcCstFrmlChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxB2_1:elgIclExcCstFrmlChrCnt" type="text" name="svapdxB2_1:elgIclExcCstFrmlChrCnt" class="chrCnt" size="6" /><span id="svapdxB2_1:elgIclExcCstFrmlChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxB2_1:panel_elgIclExcCstFrml"><textarea id="svapdxB2_1:elgIclExcCstFrml" name="svapdxB2_1:elgIclExcCstFrml" class="inputTextarea15" onkeyup="Count(this);" readonly="readonly">The state is proposing to increase the individual cost cap to 120% of the average Medicaid cost of nursing home effective 7/1/18 and to 125% of the average Medicaid cost of nursing home effective 7/1/19. All plans in excess of 100% of the average institutional cost will be subject to prior authorization by the department.</textarea></span> </div> </div> <div class="noShow"><label><input id="svapdxB2_1:elgIclExcCstCalc:2" type="radio" name="svapdxB2_1:elgIclExcCstCalc" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </div> <!-- CHECKBOX 2 --> <div class="checkboxGroup"> <label><input id="svapdxB2_1:elgIclType:2" type="radio" name="svapdxB2_1:elgIclType" value="2" onclick="return callSave(this, event);" disabled="disabled" />&#160;Institutional Cost Limit.</label> <span class="outputTextNB"> Pursuant to 42 CFR 441.301(a)(3), the State refuses entrance to the waiver to any otherwise eligible individual when the State reasonably expects that the cost of the home and community-based services furnished to that individual would exceed 100% of the cost of the level of care specified for the waiver. <em>Complete Items B-2-b and B-2-c.</em></span> </div> <!-- CHECKBOX 3 --> <div class="checkboxGroup"> <label><input id="svapdxB2_1:elgIclType:3" type="radio" name="svapdxB2_1:elgIclType" value="3" onclick="return callSave(this, event);" disabled="disabled" />&#160;Cost Limit Lower Than Institutional Costs.</label> <span class="outputTextNB"> The State refuses entrance to the waiver to any otherwise qualified individual when the State reasonably expects that the cost of home and community-based services furnished to that individual would exceed the following amount specified by the State that is less than the cost of a level of care specified for the waiver. </span> </div> <div class="firstIndent"> <p class="outputTextNB"> <label id="svapdxB2_1:lblelgIclLwrCstDscr" for="svapdxB2_1:elgIclLwrCstDscr" class="outputLabel"> <span id="svapdxB2_1:lbltxtelgIclLwrCstDscr" class="outputTextNB em">Specify the basis of the limit, including evidence that the limit is sufficient to assure the health and welfare of waiver participants. Complete Items B-2-b and B-2-c.</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxB2_1:elgIclLwrCstDscrChrCntLbl" for="svapdxB2_1:elgIclLwrCstDscrChrCnt" class="outputLabel"> <span id="svapdxB2_1:elgIclLwrCstDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxB2_1:elgIclLwrCstDscrChrCnt" type="text" name="svapdxB2_1:elgIclLwrCstDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxB2_1:elgIclLwrCstDscrChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxB2_1:panel_elgIclLwrCstDscr"><textarea id="svapdxB2_1:elgIclLwrCstDscr" name="svapdxB2_1:elgIclLwrCstDscr" class="inputTextarea15" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="firstIndent"> <p class="outputTextNB"> <strong>The cost limit specified by the State is</strong> <em>(select one)</em>: </p> <!-- CHECKBOX 3 - 0 --> <div class="checkboxGroup"> <label><input id="svapdxB2_1:elgIclLwrCstType:0" type="radio" name="svapdxB2_1:elgIclLwrCstType" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;The following dollar amount:</label> </div> <div class="firstIndent"> <p></p> <p class="outputTextNB"> <label id="svapdxB2_1:lblelgIclLwrCstAmt" for="svapdxB2_1:elgIclLwrCstAmt" class="outputLabel"> <span id="svapdxB2_1:lbltxtelgIclLwrCstAmt" class="outputTextNB">Specify dollar amount:</span></label><input id="svapdxB2_1:elgIclLwrCstAmt" type="text" name="svapdxB2_1:elgIclLwrCstAmt" class="inputTextSmall" readonly="readonly" /> </p> <div class="firstIndent"> <p class="outputTextNB"> <strong>The dollar amount</strong> <em>(select one)</em> </p> <!-- CHECKBOX 3 - 0 - 0 --> <div class="checkboxGroup"> <label><input id="svapdxB2_1:elgIclLwrCstAdj:0" type="radio" name="svapdxB2_1:elgIclLwrCstAdj" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;Is adjusted each year that the waiver is in effect by applying the following formula:</label> </div> <div class="firstIndent"> <P> <label id="svapdxB2_1:lblelgIclLwrCstFrml" for="svapdxB2_1:elgIclLwrCstFrml" class="outputLabel"> <span id="svapdxB2_1:lbltxtelgIclLwrCstFrml" class="outputTextNB">Specify the formula:</span></label> </P> <p></p> <div class="chrCntDiv"> <label id="svapdxB2_1:elgIclLwrCstFrmlChrCntLbl" for="svapdxB2_1:elgIclLwrCstFrmlChrCnt" class="outputLabel"> <span id="svapdxB2_1:elgIclLwrCstFrmlChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxB2_1:elgIclLwrCstFrmlChrCnt" type="text" name="svapdxB2_1:elgIclLwrCstFrmlChrCnt" class="chrCnt" size="6" /><span id="svapdxB2_1:elgIclLwrCstFrmlChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxB2_1:panel_elgIclLwrCstFrml"><textarea id="svapdxB2_1:elgIclLwrCstFrml" name="svapdxB2_1:elgIclLwrCstFrml" class="inputTextarea15" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <!-- CHECKBOX 3 - 0 - 1 --> <div class="checkboxGroup"> <label><input id="svapdxB2_1:elgIclLwrCstAdj:1" type="radio" name="svapdxB2_1:elgIclLwrCstAdj" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;May be adjusted during the period the waiver is in effect. The State will submit a waiver amendment to CMS to adjust the dollar amount.</label> </div> <div class="noShow"><label><input id="svapdxB2_1:elgIclLwrCstAdj:2" type="radio" name="svapdxB2_1:elgIclLwrCstAdj" checked="checked" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </div> </div> <!-- CHECKBOX 3 - 1 --> <div class="checkboxGroup"> <label><input id="svapdxB2_1:elgIclLwrCstType:1" type="radio" name="svapdxB2_1:elgIclLwrCstType" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;The following percentage that is less than 100% of the institutional average:</label> </div> <div class="firstIndent"> <p></p> <P> <label id="svapdxB2_1:lblelgIclLwrCstPct" for="svapdxB2_1:elgIclLwrCstPct" class="outputLabel"> <span id="svapdxB2_1:lbltxtelgIclLwrCstPct" class="outputTextNB">Specify percent:</span></label><input id="svapdxB2_1:elgIclLwrCstPct" type="text" name="svapdxB2_1:elgIclLwrCstPct" class="inputTextSmall" readonly="readonly" /> </P> </div> <!-- CHECKBOX 3 - 2 --> <div class="checkboxGroup"> <label><input id="svapdxB2_1:elgIclLwrCstType:2" type="radio" name="svapdxB2_1:elgIclLwrCstType" value="2" onclick="return callSave(this, event);" disabled="disabled" />&#160;Other:</label> </div> <div class="firstIndent"> <p> <label id="svapdxB2_1:lblelgIclLwrCstOthDscr" for="svapdxB2_1:elgIclLwrCstOthDscr" class="outputLabel"> <span id="svapdxB2_1:lbltxtelgIclLwrCstOthDscr" class="outputTextNB em">Specify:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxB2_1:elgIclLwrCstOthDscrChrCntLbl" for="svapdxB2_1:elgIclLwrCstOthDscrChrCnt" class="outputLabel"> <span id="svapdxB2_1:elgIclLwrCstOthDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxB2_1:elgIclLwrCstOthDscrChrCnt" type="text" name="svapdxB2_1:elgIclLwrCstOthDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxB2_1:elgIclLwrCstOthDscrChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxB2_1:panel_elgIclLwrCstOthDscr"><textarea id="svapdxB2_1:elgIclLwrCstOthDscr" name="svapdxB2_1:elgIclLwrCstOthDscr" class="inputTextarea15" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="noShow"><label><input id="svapdxB2_1:elgIclLwrCstType:3" type="radio" name="svapdxB2_1:elgIclLwrCstType" checked="checked" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </div> <div class="noShow"><label><input id="svapdxB2_1:elgIclType:4" type="radio" name="svapdxB2_1:elgIclType" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </LI> </OL> <H2 id="pageTitle">Appendix B: Participant Access and Eligibility</H2> <H3 id="pageSubTitle">B-2: Individual Cost Limit <SPAN id="pageNumber">(2 of 2)</SPAN></H3> <OL class="alphaLC" start="2"> <LI> <div class="outputTextNB"> <strong>Method of Implementation of the Individual Cost Limit.</strong> <label id="svapdxB2_2:lblelgIclMthImpl" for="svapdxB2_2:elgIclMthImpl" class="outputLabel"> <span id="svapdxB2_2:lbltxtelgIclMthImpl" class="outputTextNB">When an individual cost limit is specified in Item B-2-a, specify the procedures that are followed to determine in advance of waiver entrance that the individual's health and welfare can be assured within the cost limit:</span></label> </div> <p></p> <div class="chrCntDiv"> <label id="svapdxB2_2:elgIclMthImplChrCntLbl" for="svapdxB2_2:elgIclMthImplChrCnt" class="outputLabel"> <span id="svapdxB2_2:elgIclMthImplChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxB2_2:elgIclMthImplChrCnt" type="text" name="svapdxB2_2:elgIclMthImplChrCnt" class="chrCnt" size="6" /><span id="svapdxB2_2:elgIclMthImplChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxB2_2:panel_elgIclMthImpl"><textarea id="svapdxB2_2:elgIclMthImpl" name="svapdxB2_2:elgIclMthImpl" class="inputTextarea15" onkeyup="Count(this);" readonly="readonly">DSS must determine that the cost of waiver services necessary to ensure the individual's health and safety does not exceed identified level of care annual cost limits. The Access Agency care manager will develop a cost effective plan of care in consultation with the consumer and his/her representative if applicable. The initial plan is developed using a standardized form that requires plan development in the following areas: health, life planning, behavioral and cognitive issues, communication, risk indicators, functional assessment, and community-based supports. The Cost of Care Plan is also calculated. This plan includes all services funded under Medicaid including state plan PCA, home health care, nursing services, PT/OT, PERS, adult family living, independent support broker and assistive technology. The plan also factors in the cost of state-funded services such as Adult Day Care, Home Delivered Meals and Department of Developmental Services supports such as case management and supported living. All plans are initial plans and are reviewed and approved by Community Options Unit staff. All plans in excess of 100% of the average Medicaid cost of nursing home are subject to prior authorization by department staff. Applicants whose health and safety needs cannot be reasonably assured will first be assessed to determine if a higher service level is applicable. If this is not possible, risk mitigation agreement releases are offered to the applicant. If this is not tenable, the participant will not be enrolled or shall be discontinued from the PCA waiver. In the event that an applicant is denied enrollment, or a participant has services reduced, suspended or terminated, the applicant/participant is notified via a Medicaid Notice of Action (NOA) regarding their right to a Fair Hearing in accordance with the rules of the Department'’s Medicaid program.</textarea></span> </div> </LI> <LI> <div class="outputTextNB"> <strong>Participant Safeguards.</strong> When the State specifies an individual cost limit in Item B-2-a and there is a change in the participant's condition or circumstances post-entrance to the waiver that requires the provision of services in an amount that exceeds the cost limit in order to assure the participant's health and welfare, the State has established the following safeguards to avoid an adverse impact on the participant <em>(check each that applies)</em>: </div> <div class="checkboxGroup"> <input id="svapdxB2_2:elgIclOvrRfr" type="checkbox" name="svapdxB2_2:elgIclOvrRfr" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxB2_2:lblelgIclOvrRfr" for="svapdxB2_2:elgIclOvrRfr" class="outputLabel"> <span id="svapdxB2_2:lbltxtelgIclOvrRfr" class="outputText">The participant is referred to another waiver that can accommodate the individual's needs.</span></label> </div> <div class="checkboxGroup"> <input id="svapdxB2_2:elgIclOvrAddSvc" type="checkbox" name="svapdxB2_2:elgIclOvrAddSvc" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxB2_2:lblelgIclOvrAddSvc" for="svapdxB2_2:elgIclOvrAddSvc" class="outputLabel"> <span id="svapdxB2_2:lbltxtelgIclOvrAddSvc" class="outputText">Additional services in excess of the individual cost limit may be authorized.</span></label> </div> <div class="firstIndent"> <p class="outputTextNB"> <label id="svapdxB2_2:lblelgIclOvrAddSvcProc" for="svapdxB2_2:elgIclOvrAddSvcProc" class="outputLabel"> <span id="svapdxB2_2:lbltxtelgIclOvrAddSvcProc" class="outputTextNB">Specify the procedures for authorizing additional services, including the amount that may be authorized:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxB2_2:elgIclOvrAddSvcProcChrCntLbl" for="svapdxB2_2:elgIclOvrAddSvcProcChrCnt" class="outputLabel"> <span id="svapdxB2_2:elgIclOvrAddSvcProcChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxB2_2:elgIclOvrAddSvcProcChrCnt" type="text" name="svapdxB2_2:elgIclOvrAddSvcProcChrCnt" class="chrCnt" size="6" /><span id="svapdxB2_2:elgIclOvrAddSvcProcChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxB2_2:panel_elgIclOvrAddSvcProc"><textarea id="svapdxB2_2:elgIclOvrAddSvcProc" name="svapdxB2_2:elgIclOvrAddSvcProc" class="inputTextarea15" onkeyup="Count(this);" readonly="readonly">When a consumer's service level is thought to be inappropriate, access agency staff reassess that individual, with oversight by the Department's PCA Waiver manager. If a situation arises where a consumer has been assigned to a service level that is too low, but within waiver standards, that consumer is assigned a higher service level based on their ADL needs and their care plan is appropriately adapted. If the services cannot accommodate within an appropriate service level, it is then determined that a client does not qualify for services under the PCA Waiver. If a subsequent service reduction or termination is indicated, the client receives, as noted above, a NOA that sets forth the proposed denial/change. Clients are afforded the opportunity for a Fair Hearing in accordance with Departmental Medicaid Policy. Services cannot be reduced until the hearing decision is issued if a client requests a hearing within 10 days of the date of the NOA.</textarea></span> </div> </div> <div class="checkboxGroup"> <input id="svapdxB2_2:elgIclOvrOth" type="checkbox" name="svapdxB2_2:elgIclOvrOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxB2_2:lblelgIclOvrOth" for="svapdxB2_2:elgIclOvrOth" class="outputLabel"> <span id="svapdxB2_2:lbltxtelgIclOvrOth" class="outputText">Other safeguard(s)</span></label> </div> <div class="firstIndent"> <p> <label id="svapdxB2_2:lblelgIclOvrOthDscr" for="svapdxB2_2:elgIclOvrOthDscr" class="outputLabel"> <span id="svapdxB2_2:lbltxtelgIclOvrOthDscr" class="outputTextNB">Specify:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxB2_2:elgIclOvrOthDscrChrCntLbl" for="svapdxB2_2:elgIclOvrOthDscrChrCnt" class="outputLabel"> <span id="svapdxB2_2:elgIclOvrOthDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxB2_2:elgIclOvrOthDscrChrCnt" type="text" name="svapdxB2_2:elgIclOvrOthDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxB2_2:elgIclOvrOthDscrChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxB2_2:panel_elgIclOvrOthDscr"><textarea id="svapdxB2_2:elgIclOvrOthDscr" name="svapdxB2_2:elgIclOvrOthDscr" class="inputTextarea15" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> </LI> </OL> <H2 id="pageTitle">Appendix B: Participant Access and Eligibility</H2> <H3 id="pageSubTitle">B-3: Number of Individuals Served <SPAN id="pageNumber">(1 of 4)</SPAN></H3> <OL class="alphaLC" start="1"> <LI> <div class="outputTextNB"> <STRONG>Unduplicated Number of Participants.</STRONG> The following table specifies the maximum number of unduplicated participants who are served in each year that the waiver is in effect. The State will submit a waiver amendment to CMS to modify the number of participants specified for any year(s), including when a modification is necessary due to legislative appropriation or another reason. The number of unduplicated participants specified in this table is basis for the cost-neutrality calculations in Appendix J: </div> <TABLE id="tblelgQtyYr" border="1" cellpadding="0" cellspacing="0" class="b1Table" summary="Specify the maximum number of unduplicated participants who are served in each year that the waiver is in effect."> <CAPTION>Table: B-3-a</CAPTION> <THEAD> <TR> <TD id="wr">Waiver Year</TD> <TD id="nbrP">Unduplicated Number of Participants</TD> </TR> </THEAD> <TBODY> <TR> <TD headers="wr" class="desc">Year 1</TD> <TD headers="nbrP"> <p></p> <input id="svapdxB3_1:elgQtyYr1" type="text" name="svapdxB3_1:elgQtyYr1" value="1098" class="inputText" readonly="readonly" /> </TD> </TR> <TR> <TD headers="wr" class="desc">Year 2</TD> <TD headers="nbrP"> <p></p> <input id="svapdxB3_1:elgQtyYr2" type="text" name="svapdxB3_1:elgQtyYr2" value="1183" class="inputText" readonly="readonly" /> </TD> </TR> <TR> <TD headers="wr" class="desc">Year 3</TD> <TD headers="nbrP"> <p></p> <input id="svapdxB3_1:elgQtyYr3" type="text" name="svapdxB3_1:elgQtyYr3" value="1270" class="inputText" readonly="readonly" /> </TD> </TR> <TR> <TD headers="wr" class="desc">Year 4</TD> <TD headers="nbrP"> <p></p> <input id="svapdxB3_1:elgQtyYr4" type="text" name="svapdxB3_1:elgQtyYr4" value="1364" class="inputText" readonly="readonly" /> </TD> </TR> <TR> <TD headers="wr" class="desc">Year 5</TD> <TD headers="nbrP"> <p></p> <input id="svapdxB3_1:elgQtyYr5" type="text" name="svapdxB3_1:elgQtyYr5" value="1462" class="inputText" readonly="readonly" /> </TD> </TR> </TBODY> </TABLE> </LI> <LI> <div class="outputTextNB"> <strong>Limitation on the Number of Participants Served at Any Point in Time.</strong> Consistent with the unduplicated number of participants specified in Item B-3-a, the State may limit to a lesser number the number of participants who will be served at any point in time during a waiver year. Indicate whether the State limits the number of participants in this way: <em>(select one)</em>: </div> <table id="svapdxB3_1:elgQtyLmtd" class="selectOneRadio"> <tr> <td> <input type="radio" checked="checked" name="svapdxB3_1:elgQtyLmtd" id="svapdxB3_1:elgQtyLmtd:0" value="0" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxB3_1:elgQtyLmtd:0"> The State does not limit the number of participants that it serves at any point in time during a waiver year.</label></td> </tr> <tr> <td> <input type="radio" name="svapdxB3_1:elgQtyLmtd" id="svapdxB3_1:elgQtyLmtd:1" value="1" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxB3_1:elgQtyLmtd:1"> The State limits the number of participants that it serves at any point in time during a waiver year.</label></td> </tr> </table> <!-- rendered="#{(varFactory.elgQtyLmtd == '1') ? true : false}"> --> <div class="firstIndent"> <p><label id="lbl_tbl_elgQtyMaxYr" for="tbl_elgQtyMaxYr" class="outputTextNB">The limit that applies to each year of the waiver period is specified in the following table:</label></p> <TABLE border="1" cellpadding="0" cellspacing="0" class="b1Table" id="tbl_elgQtyMaxYr" summary="Specify the state's limits of the number of participants that it serves at any point in time for the specific years."> <CAPTION>Table: B-3-b</CAPTION> <THEAD> <TR> <TD id="wr">Waiver Year</TD> <TD id="nbrP">Maximum Number of Participants Served At Any Point During the Year</TD> </TR> </THEAD> <TBODY> <TR> <TD headers="wr" class="desc">Year 1</TD> <TD headers="nbrP"> <p></p> <input id="svapdxB3_1:elgQtyMaxYr1" type="text" name="svapdxB3_1:elgQtyMaxYr1" class="inputText" readonly="readonly" /> </TD> </TR> <TR> <TD headers="wr" class="desc">Year 2</TD> <TD headers="nbrP"> <p></p> <input id="svapdxB3_1:elgQtyMaxYr2" type="text" name="svapdxB3_1:elgQtyMaxYr2" class="inputText" readonly="readonly" /> </TD> </TR> <TR> <TD headers="wr" class="desc">Year 3</TD> <TD headers="nbrP"> <p></p> <input id="svapdxB3_1:elgQtyMaxYr3" type="text" name="svapdxB3_1:elgQtyMaxYr3" class="inputText" readonly="readonly" /> </TD> </TR> <TR> <TD headers="wr" class="desc">Year 4</TD> <TD headers="nbrP"> <p></p> <input id="svapdxB3_1:elgQtyMaxYr4" type="text" name="svapdxB3_1:elgQtyMaxYr4" class="inputText" readonly="readonly" /> </TD> </TR> <TR> <TD headers="wr" class="desc">Year 5</TD> <TD headers="nbrP"> <p></p> <input id="svapdxB3_1:elgQtyMaxYr5" type="text" name="svapdxB3_1:elgQtyMaxYr5" class="inputText" readonly="readonly" /> </TD> </TR> </TBODY> </TABLE> </div> </LI> </OL> <H2 id="pageTitle">Appendix B: Participant Access and Eligibility</H2> <H3 id="pageSubTitle">B-3: Number of Individuals Served <SPAN id="pageNumber">(2 of 4)</SPAN></H3> <OL class="alphaLC" start="3"> <LI> <div class="outputTextNB"> <strong>Reserved Waiver Capacity.</strong> The State may reserve a portion of the participant capacity of the waiver for specified purposes (e.g., provide for the community transition of institutionalized persons or furnish waiver services to individuals experiencing a crisis) subject to CMS review and approval. The State <em>(select one)</em>: </div> <table id="svapdxB3_2:elgQtyCapRsvd" class="selectOneRadio"> <tr> <td> <input type="radio" name="svapdxB3_2:elgQtyCapRsvd" id="svapdxB3_2:elgQtyCapRsvd:0" value="0" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxB3_2:elgQtyCapRsvd:0"> Not applicable. The state does not reserve capacity.</label></td> </tr> <tr> <td> <input type="radio" checked="checked" name="svapdxB3_2:elgQtyCapRsvd" id="svapdxB3_2:elgQtyCapRsvd:1" value="1" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxB3_2:elgQtyCapRsvd:1"> The State reserves capacity for the following purpose(s).</label></td> </tr> </table> <div class="firstIndent"> <label id="svapdxB3_2:lblPurpose" for="svapdxB3_2:PurposeTb" class="outputLabel"> <span id="svapdxB3_2:lbltxtPurpose" class="outputTextNB">Purpose(s) the State reserves capacity for:</span></label><table id="svapdxB3_2:PurposeTb" class="dtServices width95" border="1" cellpadding="2" cellspacing="0" summary="dynamic table of purposes the state reserves capacity" ><thead ><tr ><th scope="col" ><span class="outputText">Purposes</span></th><th scope="col" ><img src="/WMS/.ibmjsfres/img/1x1.gif" ></img></th></tr> </thead><tbody > <tr ><td ><span id="svapdxB3_2:PurposeTb:0:purposePrpTtl" class="outputText" style="width: 95%;">Money Follows the Person transition</span></td> <td ></td> </tr> </tbody> </table> <p class="pph"> </p> </div> </LI> </OL> <div class="firstIndent"> <table id="svapdxB3_2_prnt:PurposePrnt" class="nstTableX" summary="expanded table of purposes" ><tbody > <tr ><td > <H2 id="pageTitle">Appendix B: Participant Access and Eligibility</H2> <H3 id="pageSubTitle">B-3: Number of Individuals Served <SPAN id="pageNumber">(2 of 4)</SPAN></H3> <div class="firstIndent"> <p> <label id="svapdxB3_2_prnt:PurposePrnt:0:svapdxB3_2a_prnt:lblprpTtl" for="svapdxB3_2_prnt:PurposePrnt:0:svapdxB3_2a_prnt:prpTtl" class="outputLabel"> <span id="svapdxB3_2_prnt:PurposePrnt:0:svapdxB3_2a_prnt:lbltxtprpTtl" class="outputText">Purpose </span><span id="svapdxB3_2_prnt:PurposePrnt:0:svapdxB3_2a_prnt:lbltxtprpTtl2" class="outputTextNB em"> (provide a title or short description to use for lookup):</span></label> </p> <div class="inputTextareaWA"> <span id="svapdxB3_2_prnt:PurposePrnt:0:svapdxB3_2a_prnt:panel_prpTtl"><textarea id="svapdxB3_2_prnt:PurposePrnt:0:svapdxB3_2a_prnt:prpTtl" name="svapdxB3_2_prnt:PurposePrnt:0:svapdxB3_2a_prnt:prpTtl" class="inputTextarea" readonly="readonly">Money Follows the Person transition</textarea></span> </div> <div class="firstIndent"> <p> <label id="svapdxB3_2_prnt:PurposePrnt:0:svapdxB3_2a_prnt:lblprpDscr" for="svapdxB3_2_prnt:PurposePrnt:0:svapdxB3_2a_prnt:prpDscr" class="outputLabel"> <span id="svapdxB3_2_prnt:PurposePrnt:0:svapdxB3_2a_prnt:lbltxtprpDscr" class="outputText">Purpose </span><span id="svapdxB3_2_prnt:PurposePrnt:0:svapdxB3_2a_prnt:lbltxtprpDscr2" class="outputTextNB em"> (describe):</span></label> </p> <div class="inputTextareaWA"> <span id="svapdxB3_2_prnt:PurposePrnt:0:svapdxB3_2a_prnt:panel_prpDscr"><textarea id="svapdxB3_2_prnt:PurposePrnt:0:svapdxB3_2a_prnt:prpDscr" name="svapdxB3_2_prnt:PurposePrnt:0:svapdxB3_2a_prnt:prpDscr" class="inputTextarea" readonly="readonly">PCA Waiver that will be used for clients transitioning from Money Folows the Person (MFP) onto the PCA Waiver.</textarea></span> </div> <p> <label id="svapdxB3_2_prnt:PurposePrnt:0:svapdxB3_2a_prnt:lblprpCapDscr" for="svapdxB3_2_prnt:PurposePrnt:0:svapdxB3_2a_prnt:prpCapDscr" class="outputLabel"> <span id="svapdxB3_2_prnt:PurposePrnt:0:svapdxB3_2a_prnt:lbltxtprpCapDscr" class="outputText">Describe how the amount of reserved capacity was determined:</span></label> </p> <div class="inputTextareaWA"> <span id="svapdxB3_2_prnt:PurposePrnt:0:svapdxB3_2a_prnt:panel_prpCapDscr"><textarea id="svapdxB3_2_prnt:PurposePrnt:0:svapdxB3_2a_prnt:prpCapDscr" name="svapdxB3_2_prnt:PurposePrnt:0:svapdxB3_2a_prnt:prpCapDscr" class="inputTextarea" readonly="readonly">These clients will need to transition off the MFP Waiver and onto the PCA Waiver over the next five years.</textarea></span> </div> <div class="pph"> <p><label id="lblPrpCap" for="tablePrpCap" class="outputText">The capacity that the State reserves in each waiver year is specified in the following table:</label></p> <table id="tablePrpCap" border="1" cellpadding="0" cellspacing="0" class="b1Table" summary="Specify the capacity that the State reserves in each waiver year"> <thead> <tr> <td id="wr">Waiver Year</td> <td id="cr">Capacity Reserved</td> </tr> </thead> <tbody> <tr> <td headers="wr" class="desc">Year 1</td> <td headers="cr"> <input id="svapdxB3_2_prnt:PurposePrnt:0:svapdxB3_2a_prnt:yr1" type="text" name="svapdxB3_2_prnt:PurposePrnt:0:svapdxB3_2a_prnt:yr1" value="84" class="inputText" readonly="readonly" /> </td> </tr> <tr> <td headers="wr" class="desc">Year 2</td> <td headers="cr"> <input id="svapdxB3_2_prnt:PurposePrnt:0:svapdxB3_2a_prnt:yr2" type="text" name="svapdxB3_2_prnt:PurposePrnt:0:svapdxB3_2a_prnt:yr2" value="108" class="inputText" readonly="readonly" /> </td> </tr> <tr> <td headers="wr" class="desc">Year 3</td> <td headers="cr"> <input id="svapdxB3_2_prnt:PurposePrnt:0:svapdxB3_2a_prnt:yr3" type="text" name="svapdxB3_2_prnt:PurposePrnt:0:svapdxB3_2a_prnt:yr3" value="120" class="inputText" readonly="readonly" /> </td> </tr> <tr> <td headers="wr" class="desc">Year 4</td> <td headers="cr"> <input id="svapdxB3_2_prnt:PurposePrnt:0:svapdxB3_2a_prnt:yr4" type="text" name="svapdxB3_2_prnt:PurposePrnt:0:svapdxB3_2a_prnt:yr4" value="132" class="inputText" readonly="readonly" /> </td> </tr> <tr> <td headers="wr" class="desc">Year 5</td> <TD headers="cr"> <input id="svapdxB3_2_prnt:PurposePrnt:0:svapdxB3_2a_prnt:yr5" type="text" name="svapdxB3_2_prnt:PurposePrnt:0:svapdxB3_2a_prnt:yr5" value="144" class="inputText" readonly="readonly" /> </td> </tr> </tbody> </table> </div> </div> <table class="drillButtons"> <tr> <td class="btnLft"> </td> <td class="btnRgt"> </td> </tr> </table> </div> </td> </tr> </tbody> </table> </div> <H2 id="pageTitle">Appendix B: Participant Access and Eligibility</H2> <H3 id="pageSubTitle">B-3: Number of Individuals Served <SPAN id="pageNumber">(3 of 4)</SPAN></H3> <OL class="alphaLC" start="4"> <LI> <div class="outputTextNB"> <strong>Scheduled Phase-In or Phase-Out.</strong> Within a waiver year, the State may make the number of participants who are served subject to a phase-in or phase-out schedule <em>(select one)</em>: </div> <table id="svapdxB3_3:elgQtyPhsSch" class="selectOneRadio"> <tr> <td> <input type="radio" checked="checked" name="svapdxB3_3:elgQtyPhsSch" id="svapdxB3_3:elgQtyPhsSch:0" value="0" disabled="disabled" /><label for="svapdxB3_3:elgQtyPhsSch:0"> The waiver is not subject to a phase-in or a phase-out schedule.</label></td> </tr> <tr> <td> <input type="radio" name="svapdxB3_3:elgQtyPhsSch" id="svapdxB3_3:elgQtyPhsSch:1" value="1" disabled="disabled" /><label for="svapdxB3_3:elgQtyPhsSch:1"> The waiver is subject to a phase-in or phase-out schedule that is included in Attachment #1 to Appendix B-3. This schedule constitutes an intra-year limitation on the number of participants who are served in the waiver.</label></td> </tr> </table> </LI> <LI> <div class="outputTextNB"> <strong>Allocation of Waiver Capacity.</strong> <p><em>Select one</em>:</p> </div> <table id="svapdxB3_3:elgQtyCapAlcType" class="selectOneRadio"> <tr> <td> <input type="radio" checked="checked" name="svapdxB3_3:elgQtyCapAlcType" id="svapdxB3_3:elgQtyCapAlcType:0" value="0" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxB3_3:elgQtyCapAlcType:0"> Waiver capacity is allocated/managed on a statewide basis.</label></td> </tr> <tr> <td> <input type="radio" name="svapdxB3_3:elgQtyCapAlcType" id="svapdxB3_3:elgQtyCapAlcType:1" value="1" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxB3_3:elgQtyCapAlcType:1"> Waiver capacity is allocated to local/regional non-state entities.</label></td> </tr> </table> <div class="firstIndent"> <p> <label id="svapdxB3_3:lblelgQtyCapAlcDscr" for="svapdxB3_3:elgQtyCapAlcDscr" class="outputLabel"> <span id="svapdxB3_3:lbltxtelgQtyCapAlcDscr" class="outputTextNB">Specify: (a) the entities to which waiver capacity is allocated; (b) the methodology that is used to allocate capacity and how often the methodology is reevaluated; and, (c) policies for the reallocation of unused capacity among local/regional non-state entities:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxB3_3:elgQtyCapAlcDscrChrCntLbl" for="svapdxB3_3:elgQtyCapAlcDscrChrCnt" class="outputLabel"> <span id="svapdxB3_3:elgQtyCapAlcDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxB3_3:elgQtyCapAlcDscrChrCnt" type="text" name="svapdxB3_3:elgQtyCapAlcDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxB3_3:elgQtyCapAlcDscrChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxB3_3:panel_elgQtyCapAlcDscr"><textarea id="svapdxB3_3:elgQtyCapAlcDscr" name="svapdxB3_3:elgQtyCapAlcDscr" class="inputTextarea15" onkeyup="Count(this)" readonly="readonly"></textarea></span> </div> </div> </LI> <LI> <div class="outputTextNB"> <strong>Selection of Entrants to the Waiver.</strong> <label id="svapdxB3_3:lblelgQtySelPlcy" for="svapdxB3_3:elgQtySelPlcy" class="outputLabel"> <span id="svapdxB3_3:lbltxtelgQtySelPlcy" class="outputTextNB">Specify the policies that apply to the selection of individuals for entrance to the waiver:</span></label> </div> <p></p> <div class="chrCntDiv"> <label id="svapdxB3_3:elgQtySelPlcyChrCntLbl" for="svapdxB3_3:elgQtySelPlcyChrCnt" class="outputLabel"> <span id="svapdxB3_3:elgQtySelPlcyChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxB3_3:elgQtySelPlcyChrCnt" type="text" name="svapdxB3_3:elgQtySelPlcyChrCnt" class="chrCnt" size="6" /><span id="svapdxB3_3:elgQtySelPlcyChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxB3_3:panel_elgQtySelPlcy"><textarea id="svapdxB3_3:elgQtySelPlcy" name="svapdxB3_3:elgQtySelPlcy" class="inputTextarea15" onkeyup="Count(this);" readonly="readonly">All applicant for the PCA waiver shall meet all the requirements for eligibility in the Department's medical assistance program that are applicable to disabled adults as stated in the regulations promulgated by the Department and contained in the Uniform Policy Manual pursuant to Section 17b-10 of the Connecticut General Statutes. This includes without limitation all regulations establishing medical assistance eligibility requirements related to the filing of applicants for assistance, verifications, and redeterminations, existence of a disabling condition, citizenship status, residency, institutional status, assistance unit composition and income and asset limits. Waiting List: If an individual applies for the PCA waiver services at a time when the participant cap has been reached, his or her application shall be reviewed and processed for financial eligibility and fulfillment of the level of care criteria. An otherwise eligible individual who is denied solely because of the program quota shall be placed on the Department's waiting list for the PCA program. This list will be generated by the fiscal intermediary utilizing the date the client made application to the program. The date of application will determine the numerical location of the client on the waitlist.</textarea></span> </div> </LI> </OL> <H2 id="pageTitle">Appendix B: Participant Access and Eligibility</H2> <H3 id="pageSubTitle">B-3: Number of Individuals Served - Attachment #1 <SPAN id="pageNumber">(4 of 4)</SPAN></H3> <p class="outputText pph underline"> Answers provided in Appendix B-3-d indicate that you do not need to complete this section. </p> <H2 id="pageTitle">Appendix B: Participant Access and Eligibility</H2> <H3 id="pageSubTitle">B-4: Eligibility Groups Served in the Waiver<SPAN id="pageNumber"></SPAN></H3> <div class="firstIndent"> </div> <OL class="alphaLC" start="1"> <LI style="padding-bottom: 1em;"><div> <ol class="numeric" start="1"> <li> <div class="outputTextNB"> <strong>State Classification.</strong> The State is a <em>(select one)</em>: </div> <div class="checkboxGroup"><label><input id="svapdxB4_1:elgStClass:0" type="radio" name="svapdxB4_1:elgStClass" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;&sect;1634 State</label></div> <div class="checkboxGroup"><label><input id="svapdxB4_1:elgStClass:1" type="radio" name="svapdxB4_1:elgStClass" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;SSI Criteria State</label></div> <div class="checkboxGroup"><label><input id="svapdxB4_1:elgStClass:2" type="radio" name="svapdxB4_1:elgStClass" checked="checked" value="2" onclick="return callSave(this, event);" disabled="disabled" />&#160;209(b) State</label></div> <div class="noShow"><label><input id="svapdxB4_1:elgStClass:3" type="radio" name="svapdxB4_1:elgStClass" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </li> <li> <div class="outputTextNB" style="padding-top: 1em;"> <strong>Miller Trust State.</strong> </div> <div class="outputTextNB" style=""> Indicate whether the State is a Miller Trust State <em>(select one)</em>: </div> <div class="checkboxGroup"><label><input id="svapdxB4_1:millTrStYN:0" type="radio" name="svapdxB4_1:millTrStYN" checked="checked" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;No</label></div> <div class="checkboxGroup"><label><input id="svapdxB4_1:millTrStYN:1" type="radio" name="svapdxB4_1:millTrStYN" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;Yes</label></div> <div class="noShow"><label><input id="svapdxB4_1:millTrStYN:2" type="radio" name="svapdxB4_1:millTrStYN" value="2" onclick="return callSave(this, event);" disabled="disabled" />&#160;Unknown</label></div> </li> </ol> </div> </LI> <LI> <div class="outputTextNB"> <strong>Medicaid Eligibility Groups Served in the Waiver.</strong> Individuals who receive services under this waiver are eligible under the following eligibility groups contained in the State plan. The State applies all applicable federal financial participation limits under the plan. <em>Check all that apply</em>: </div> <div class="outputTextNB underline"> <em><strong>Eligibility Groups Served in the Waiver (excluding the special home and community-based waiver group under 42 CFR §435.217)</strong></em> </div> <div class="checkboxGroup"> <input id="svapdxB4_1:elgGrpSec1931" type="checkbox" name="svapdxB4_1:elgGrpSec1931" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxB4_1:lblelgGrpSec1931" for="svapdxB4_1:elgGrpSec1931" class="outputLabel"> <span id="svapdxB4_1:lbltxtelgGrpSec1931" class="outputText">Low income families with children as provided in &sect;1931 of the Act</span></label> </div> <div class="checkboxGroup"> <input id="svapdxB4_1:elgGrpSSIRcp" type="checkbox" name="svapdxB4_1:elgGrpSSIRcp" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxB4_1:lblelgGrpSSIRcp" for="svapdxB4_1:elgGrpSSIRcp" class="outputLabel"> <span id="svapdxB4_1:lbltxtelgGrpSSIRcp" class="outputText">SSI recipients</span></label> </div> <div class="checkboxGroup"> <input id="svapdxB4_1:elgGrpAbd" type="checkbox" name="svapdxB4_1:elgGrpAbd" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxB4_1:lblelgGrpAbd" for="svapdxB4_1:elgGrpAbd" class="outputLabel"> <span id="svapdxB4_1:lbltxtelgGrpAbd" class="outputText">Aged, blind or disabled in 209(b) states who are eligible under 42 CFR &sect;435.121</span></label> </div> <div class="checkboxGroup"> <input id="svapdxB4_1:elgGrpStSupRec" type="checkbox" name="svapdxB4_1:elgGrpStSupRec" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxB4_1:lblelgGrpStSupRec" for="svapdxB4_1:elgGrpStSupRec" class="outputLabel"> <span id="svapdxB4_1:lbltxtelgGrpStSupRec" class="outputText">Optional State supplement recipients</span></label> </div> <div class="checkboxGroup"> <input id="svapdxB4_1:elgGrpCatNdy" type="checkbox" name="svapdxB4_1:elgGrpCatNdy" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxB4_1:lblelgGrpCatNdy" for="svapdxB4_1:elgGrpCatNdy" class="outputLabel"> <span id="svapdxB4_1:lbltxtelgGrpCatNdy" class="outputText">Optional categorically needy aged and/or disabled individuals who have income at:</span></label> </div> <div class="firstIndent"> <p class="outputTextNB"><em>Select one</em>:</p> <div class="checkboxGroup"> <label><input id="svapdxB4_1:elgGrpCatNdyType:0" type="radio" name="svapdxB4_1:elgGrpCatNdyType" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;100% of the Federal poverty level (FPL)</label> </div> <div class="checkboxGroup"> <label><input id="svapdxB4_1:elgGrpCatNdyType:1" type="radio" name="svapdxB4_1:elgGrpCatNdyType" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;% of FPL, which is lower than 100% of FPL.</label> </div> <div class="firstIndent"> <p></p> <label id="svapdxB4_1:lblelgGrpCatNdyFPLPct" for="svapdxB4_1:elgGrpCatNdyFPLPct" class="outputLabel"> <span id="svapdxB4_1:lbltxtelgGrpCatNdyFPLPct" class="outputTextNB">Specify percentage:</span></label><input id="svapdxB4_1:elgGrpCatNdyFPLPct" type="text" name="svapdxB4_1:elgGrpCatNdyFPLPct" class="inputTextSmall" readonly="readonly" /> </div> <div class="noShow"><label><input id="svapdxB4_1:elgGrpCatNdyType:2" type="radio" name="svapdxB4_1:elgGrpCatNdyType" checked="checked" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </div> <div class="checkboxGroup"> <input id="svapdxB4_1:elgGrpWrkDisBBA" type="checkbox" name="svapdxB4_1:elgGrpWrkDisBBA" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxB4_1:lblelgGrpWrkDisBBA" for="svapdxB4_1:elgGrpWrkDisBBA" class="outputLabel"> <span id="svapdxB4_1:lbltxtelgGrpWrkDisBBA" class="outputText">Working individuals with disabilities who buy into Medicaid (BBA working disabled group as provided in &sect;1902(a)(10)(A)(ii)(XIII)) of the Act)</span></label> </div> <div class="checkboxGroup"> <input id="svapdxB4_1:elgGrpWrkDisTBCG" type="checkbox" name="svapdxB4_1:elgGrpWrkDisTBCG" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxB4_1:lblelgGrpWrkDisTBCG" for="svapdxB4_1:elgGrpWrkDisTBCG" class="outputLabel"> <span id="svapdxB4_1:lbltxtelgGrpWrkDisTBCG" class="outputText">Working individuals with disabilities who buy into Medicaid (TWWIIA Basic Coverage Group as provided in &sect;1902(a)(10)(A)(ii)(XV) of the Act)</span></label> </div> <div class="checkboxGroup"> <input id="svapdxB4_1:elgGrpWrkDisTMICG" type="checkbox" name="svapdxB4_1:elgGrpWrkDisTMICG" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxB4_1:lblelgGrpWrkDisTMICG" for="svapdxB4_1:elgGrpWrkDisTMICG" class="outputLabel"> <span id="svapdxB4_1:lbltxtelgGrpWrkDisTMICG" class="outputText">Working individuals with disabilities who buy into Medicaid (TWWIIA Medical Improvement Coverage Group as provided in &sect;1902(a)(10)(A)(ii)(XVI) of the Act)</span></label> </div> <div class="checkboxGroup"> <input id="svapdxB4_1:elgGrpDisTEFRA134" type="checkbox" name="svapdxB4_1:elgGrpDisTEFRA134" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxB4_1:lblelgGrpDisTEFRA134" for="svapdxB4_1:elgGrpDisTEFRA134" class="outputLabel"> <span id="svapdxB4_1:lbltxtelgGrpDisTEFRA134" class="outputText">Disabled individuals age 18 or younger who would require an institutional level of care (TEFRA 134 eligibility group as provided in &sect;1902(e)(3) of the Act)</span></label> </div> <div class="noShow"> <input id="svapdxB4_1:elgGrpMedNdy" type="checkbox" name="svapdxB4_1:elgGrpMedNdy" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxB4_1:lblelgGrpMedNdy" for="svapdxB4_1:elgGrpMedNdy" class="outputLabel"> <span id="svapdxB4_1:lbltxtelgGrpMedNdy" class="outputText">Medically needy</span></label> </div> <div class="checkboxGroup"> <input id="svapdxB4_1:elgGrpMedNdy209" type="checkbox" name="svapdxB4_1:elgGrpMedNdy209" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxB4_1:lblelgGrpMedNdy209" for="svapdxB4_1:elgGrpMedNdy209" class="outputLabel"> <span id="svapdxB4_1:lbltxtelgGrpMedNdy209" class="outputText">Medically needy in 209(b) States (42 CFR &sect;435.330)</span></label> </div> <div class="checkboxGroup"> <input id="svapdxB4_1:elgGrpMedNdySSI" type="checkbox" name="svapdxB4_1:elgGrpMedNdySSI" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxB4_1:lblelgGrpMedNdySSI" for="svapdxB4_1:elgGrpMedNdySSI" class="outputLabel"> <span id="svapdxB4_1:lbltxtelgGrpMedNdySSI" class="outputText">Medically needy in 1634 States and SSI Criteria States (42 CFR &sect;435.320, &sect;435.322 and &sect;435.324)</span></label> </div> <div class="checkboxGroup"> <input id="svapdxB4_1:elgGrpOth" type="checkbox" name="svapdxB4_1:elgGrpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxB4_1:lblelgGrpOth" for="svapdxB4_1:elgGrpOth" class="outputLabel"> <span id="svapdxB4_1:lbltxtelgGrpOth" class="outputText">Other specified groups (include only statutory/regulatory reference to reflect the additional groups in the State plan that may receive services under this waiver)</span></label> </div> <div class="firstIndent"> <p class="outputTextNB"> <label id="svapdxB4_1:lblelgGrpOthDscr" for="svapdxB4_1:elgGrpOthDscr" class="outputLabel"> <span id="svapdxB4_1:lbltxtelgGrpOthDscr" class="outputTextNB em">Specify:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxB4_1:elgGrpOthDscrChrCntLbl" for="svapdxB4_1:elgGrpOthDscrChrCnt" class="outputLabel"> <span id="svapdxB4_1:elgGrpOthDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxB4_1:elgGrpOthDscrChrCnt" type="text" name="svapdxB4_1:elgGrpOthDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxB4_1:elgGrpOthDscrChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxB4_1:panel_elgGrpOthDscr"><textarea id="svapdxB4_1:elgGrpOthDscr" name="svapdxB4_1:elgGrpOthDscr" class="inputTextarea15" onkeyup="Count(this);" readonly="readonly">Person's defined as qualified severly impaired individuals in section 1619b and 1905(q) of the social security act.</textarea></span> </div> </div> <div class="outputTextNB underline"> <em><strong>Special home and community-based waiver group under 42 CFR §435.217)</strong> Note: When the special home and community-based waiver group under 42 CFR §435.217 is included, Appendix B-5 must be completed</em> </div> <div> <div class="checkboxGroup"> <label><input id="svapdxB4_1:elgGrpSpecHomCom:0" type="radio" name="svapdxB4_1:elgGrpSpecHomCom" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;No.</label> <span class="outputTextNB"> <strong>The 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class="outputTextNB"><em>Select one and complete Appendix B-5.</em></label></p> <div class="checkboxGroup"> <label><input id="svapdxB4_1:elgGrp435Type:0" type="radio" name="svapdxB4_1:elgGrp435Type" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;All individuals in the special home and community-based waiver group under 42 CFR &sect;435.217</label> </div> <div class="checkboxGroup"> <label><input id="svapdxB4_1:elgGrp435Type:1" type="radio" name="svapdxB4_1:elgGrp435Type" checked="checked" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;Only the following groups of individuals in the special home and community-based waiver group under 42 CFR &sect;435.217</label> </div> <div class="noShow"><label><input id="svapdxB4_1:elgGrp435Type:2" type="radio" name="svapdxB4_1:elgGrp435Type" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> <!-- rendered="#{(varFactory.elgGrp435Type == 1)?true:false}"> --> <div class="firstIndent"> <p class="outputTextNB"><em>Check each that applies</em>:</p> <div> <div class="checkboxGroup"> <input id="svapdxB4_1:elgGrp435IncLvl" type="checkbox" name="svapdxB4_1:elgGrp435IncLvl" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxB4_1:lblelgGrp435IncLvl" for="svapdxB4_1:elgGrp435IncLvl" class="outputLabel"> <span id="svapdxB4_1:lbltxtelgGrp435IncLvl" class="outputText">A special income level equal to:</span></label> </div> <div class="firstIndent"> <p class="outputTextNB"><em>Select one</em>:</p> <div class="checkboxGroup"><label><input id="svapdxB4_1:elgGrp435IncQual:0" type="radio" name="svapdxB4_1:elgGrp435IncQual" checked="checked" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;300% of the SSI Federal Benefit Rate (FBR)</label></div> <div class="checkboxGroup"> <label><input id="svapdxB4_1:elgGrp435IncQual:1" type="radio" name="svapdxB4_1:elgGrp435IncQual" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;A percentage of FBR, which is lower than 300% (42 CFR &sect;435.236)</label> </div> <div class="firstIndent"> <p></p> <label id="svapdxB4_1:lblelgGrp435IncQualPct" for="svapdxB4_1:elgGrp435IncQualPct" class="outputLabel"> <span id="svapdxB4_1:lbltxtelgGrp435IncQualPct" class="outputTextNB">Specify percentage: </span></label><input id="svapdxB4_1:elgGrp435IncQualPct" type="text" name="svapdxB4_1:elgGrp435IncQualPct" class="inputTextSmall" readonly="readonly" /> </div> <div class="checkboxGroup"> <label><input id="svapdxB4_1:elgGrp435IncQual:2" type="radio" name="svapdxB4_1:elgGrp435IncQual" value="2" onclick="return callSave(this, event);" disabled="disabled" />&#160;A dollar amount which is lower than 300%.</label> </div> <div class="firstIndent"> <p></p> <label id="svapdxB4_1:lblelgGrp435IncQualAmt" for="svapdxB4_1:elgGrp435IncQualAmt" class="outputLabel"> <span id="svapdxB4_1:lbltxtelgGrp435IncQualAmt" class="outputTextNB">Specify dollar amount: </span></label><input id="svapdxB4_1:elgGrp435IncQualAmt" type="text" name="svapdxB4_1:elgGrp435IncQualAmt" class="inputTextSmall" readonly="readonly" /> </div> <div class="noShow"><label><input id="svapdxB4_1:elgGrp435IncQual:3" type="radio" name="svapdxB4_1:elgGrp435IncQual" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </div> </div> <div class="checkboxGroup"> <input id="svapdxB4_1:elgGrp435ABD" type="checkbox" name="svapdxB4_1:elgGrp435ABD" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxB4_1:lblelgGrp435ABD" for="svapdxB4_1:elgGrp435ABD" class="outputLabel"> <span id="svapdxB4_1:lbltxtelgGrp435ABD" class="outputText">Aged, blind and disabled individuals who meet requirements that are more restrictive than the SSI program (42 CFR &sect;435.121)</span></label> </div> <div class="checkboxGroup"> <input id="svapdxB4_1:elgGrp435NdySSI" type="checkbox" name="svapdxB4_1:elgGrp435NdySSI" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxB4_1:lblelgGrp435NdySSI" for="svapdxB4_1:elgGrp435NdySSI" class="outputLabel"> <span id="svapdxB4_1:lbltxtelgGrp435NdySSI" class="outputText">Medically needy without spenddown in States which also provide Medicaid to recipients of SSI (42 CFR &sect;435.320, &sect;435.322 and &sect;435.324)</span></label> </div> <div class="checkboxGroup"> <input id="svapdxB4_1:elgGrp435Ndy209" type="checkbox" name="svapdxB4_1:elgGrp435Ndy209" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxB4_1:lblelgGrp435Ndy209" for="svapdxB4_1:elgGrp435Ndy209" class="outputLabel"> <span id="svapdxB4_1:lbltxtelgGrp435Ndy209" class="outputText">Medically needy without spend down in 209(b) States (42 CFR &sect;435.330)</span></label> </div> <div class="checkboxGroup"> <input id="svapdxB4_1:elgGrp435AD" type="checkbox" name="svapdxB4_1:elgGrp435AD" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxB4_1:lblelgGrp435AD" for="svapdxB4_1:elgGrp435AD" class="outputLabel"> <span id="svapdxB4_1:lbltxtelgGrp435AD" class="outputText">Aged and disabled individuals who have income at:</span></label> </div> <div class="firstIndent"> <p class="outputTextNB"><em>Select one</em>:</p> <div class="checkboxGroup"> <label><input id="svapdxB4_1:elgGrp435ADQualType:0" type="radio" name="svapdxB4_1:elgGrp435ADQualType" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;100% of FPL </label> </div> <div class="checkboxGroup"> <label><input id="svapdxB4_1:elgGrp435ADQualType:1" type="radio" name="svapdxB4_1:elgGrp435ADQualType" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;% of FPL, which is lower than 100%.</label> </div> <div class="firstIndent"> <p></p> <label id="svapdxB4_1:lblelgGrp435ADQualPct" for="svapdxB4_1:elgGrp435ADQualPct" class="outputLabel"> <span id="svapdxB4_1:lbltxtelgGrp435ADQualPct" class="outputTextNB">Specify percentage amount:</span></label><input id="svapdxB4_1:elgGrp435ADQualPct" type="text" name="svapdxB4_1:elgGrp435ADQualPct" class="inputTextSmall" readonly="readonly" /> </div> <div class="noShow"><label><input id="svapdxB4_1:elgGrp435ADQualType:2" type="radio" name="svapdxB4_1:elgGrp435ADQualType" checked="checked" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </div> <div class="checkboxGroup"> <input id="svapdxB4_1:elgGrp435Oth" type="checkbox" name="svapdxB4_1:elgGrp435Oth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxB4_1:lblelgGrp435Oth" for="svapdxB4_1:elgGrp435Oth" class="outputLabel"> <span id="svapdxB4_1:lbltxtelgGrp435Oth" class="outputText">Other specified groups (include only statutory/regulatory reference to reflect the additional groups in the State plan that may receive services under this waiver)</span></label> </div> <div class="firstIndent"> <p class="outputTextNB"> <label id="svapdxB4_1:lblelgGrp435OthDscr" for="svapdxB4_1:elgGrp435OthDscr" class="outputLabel"> <span id="svapdxB4_1:lbltxtelgGrp435OthDscr" class="outputTextNB em">Specify:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxB4_1:elgGrp435OthDscrChrCntLbl" for="svapdxB4_1:elgGrp435OthDscrChrCnt" class="outputLabel"> <span id="svapdxB4_1:elgGrp435OthDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxB4_1:elgGrp435OthDscrChrCnt" type="text" name="svapdxB4_1:elgGrp435OthDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxB4_1:elgGrp435OthDscrChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxB4_1:panel_elgGrp435OthDscr"><textarea id="svapdxB4_1:elgGrp435OthDscr" name="svapdxB4_1:elgGrp435OthDscr" class="inputTextarea15" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> </div> </div> </LI> </OL> <H2 id="pageTitle">Appendix B: Participant Access and Eligibility</H2> <H3 id="pageSubTitle">B-5: Post-Eligibility Treatment of Income <SPAN id="pageNumber">(1 of 7)</SPAN></H3> <P class="outputTextNB"><EM>In accordance with 42 CFR §441.303(e), Appendix B-5 must be completed when the State furnishes waiver services to individuals in the special home and community-based waiver group under 42 CFR §435.217, as indicated in Appendix B-4. Post-eligibility applies only to the 42 CFR §435.217 group.</EM></P> <OL class="alphaLC" start="1"> <LI> <p class="outputTextNB"> <strong>Use of Spousal Impoverishment Rules.</strong> Indicate whether spousal impoverishment rules are used to determine eligibility for the special home and community-based waiver group under 42 CFR §435.217: </p> <div class="pph"> <span id="svapdxB5_1:newInstr1" class="outputTextNB em">Note: For the five-year period beginning January 1, 2014, the following instructions are mandatory. The following box should be checked for all waivers that furnish waiver services to the 42 CFR &sect;435.217 group effective at any point during this time period.</span> </div> <div class="checkboxGroup"> <input id="svapdxB5_1:elgIncSpoImpRls_2014" type="checkbox" name="svapdxB5_1:elgIncSpoImpRls_2014" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxB5_1:lblelgIncSpoImpRls_2014" for="svapdxB5_1:elgIncSpoImpRls_2014" class="outputLabel"> <span id="svapdxB5_1:lbltxtelgIncSpoImpRls_2014a" class="outputText">Spousal impoverishment rules under &sect;1924 of the Act are used to determine the eligibility of individuals with a community spouse for the special home and community-based waiver group. In the case of a participant with a community spouse, the State uses </span><span id="svapdxB5_1:lbltxtelgIncSpoImpRls_2014b" class="outputText em">spousal </span><span id="svapdxB5_1:lbltxtelgIncSpoImpRls_2014c" class="outputText">post-eligibility rules under &sect;1924 of the Act. </span></label> </div> <div class="firstIndent"> <span id="svapdxB5_1:lbltxtelgIncSpoImpRls_2014d" class="outputTextNB em">Complete Items B-5-e (if the selection for B-4-a-i is SSI State or &sect;1634) or B-5-f (if the selection for B-4-a-i is 209b State) </span><span id="svapdxB5_1:lbltxtelgIncSpoImpRls_2014e" class="outputTextNB em ul">and</span><span id="svapdxB5_1:lbltxtelgIncSpoImpRls_2014f" class="outputTextNB em"> Item B-5-g unless the state indicates that it also uses spousal post-eligibility rules for the time periods before January 1, 2014 or after December 31, 2018.</span> </div> <div class="pph"> <span id="svapdxB5_1:newInstr2" class="outputTextNB em">Note: The following selections apply for the time periods before January 1, 2014 or after December 31, 2018 (select one).</span> </div> <div class="pph"> <div class="checkboxGroup"> <label><input id="svapdxB5_1:elgIncSpoImpRls:0" type="radio" name="svapdxB5_1:elgIncSpoImpRls" checked="checked" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;Spousal impoverishment rules under &sect;1924 of the Act are used to determine the eligibility of individuals with a community spouse for the special home and community-based waiver group.</label> </div> <div class="firstIndent"> <p class="outputTextNB"> In the case of a participant with a community spouse, the State elects to (<em>select one</em>): </p> <div class="checkboxGroup"> <label><input id="svapdxB5_1:elgIncSpoImpRlsType:0" type="radio" name="svapdxB5_1:elgIncSpoImpRlsType" checked="checked" value="0" disabled="disabled" />&#160;Use spousal post-eligibility rules under &sect;1924 of the Act.</label> </div> <div class="firstIndent"> <span id="svapdxB5_1:text7" class="outputTextNB em">(Complete Item B-5-c (209b State)</span><span id="svapdxB5_1:text10" class="outputTextNB em"> and Item B-5-d)</span> </div> <div class="checkboxGroup"> <label><input id="svapdxB5_1:elgIncSpoImpRlsType:1" type="radio" name="svapdxB5_1:elgIncSpoImpRlsType" value="1" disabled="disabled" />&#160;Use regular post-eligibility rules under 42 CFR &sect;435.726 (SSI State) or under &sect;435.735 (209b State)</label> </div> <div class="firstIndent"> <span id="svapdxB5_1:text4" class="outputTextNB em">(Complete Item B-5-c (209b State)</span><span id="svapdxB5_1:text20" class="outputTextNB em">. Do not complete Item B-5-d)</span> </div> <div class="noShow"><label><input id="svapdxB5_1:elgIncSpoImpRlsType:2" type="radio" name="svapdxB5_1:elgIncSpoImpRlsType" value="99" disabled="disabled" />&#160;not selected</label></div> </div> <div class="checkboxGroup"> <label><input id="svapdxB5_1:elgIncSpoImpRls:1" type="radio" name="svapdxB5_1:elgIncSpoImpRls" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;Spousal impoverishment rules under &sect;1924 of the Act are not used to determine eligibility of individuals with a community spouse for the special home and community-based waiver group. The State uses regular post-eligibility rules for individuals with a community spouse.</label> </div> <div class="firstIndent"> <span id="svapdxB5_1:text1" class="outputTextNB em">(Complete Item B-5-c (209b State)</span><span id="svapdxB5_1:text21" class="outputTextNB em">. Do not complete Item B-5-d)</span> </div> <div class="noShow"><label><input id="svapdxB5_1:elgIncSpoImpRls:2" type="radio" name="svapdxB5_1:elgIncSpoImpRls" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </div> </LI> </OL> <H2 id="pageTitle">Appendix B: Participant Access and Eligibility</H2> <H3 id="pageSubTitle">B-5: Post-Eligibility Treatment of Income <SPAN id="pageNumber">(2 of 7)</SPAN></H3> <div class="pph"> <span id="svapdxB5_2:newInstr2" class="outputTextNB em">Note: The following selections apply for the time periods before January 1, 2014 or after December 31, 2018.</span> </div> <OL class="alphaLC" start="2"> <LI> <p class="outputTextNB"> <span id="svapdxB5_2:questionB5bTitle1" class="outputText">Regular Post-Eligibility Treatment of Income: SSI State.</span> </p> <div> <p class="pph underline bld"> Answers provided in Appendix B-4 indicate that you do not need to complete this section and therefore this section is not visible. </p> </div> </LI> </OL> <H2 id="pageTitle">Appendix B: Participant Access and Eligibility</H2> <H3 id="pageSubTitle">B-5: Post-Eligibility Treatment of Income <SPAN id="pageNumber">(3 of 7)</SPAN></H3> <div class="pph"> <span id="svapdxB5_3:newInstr2" class="outputTextNB em">Note: The following selections apply for the time periods before January 1, 2014 or after December 31, 2018.</span> </div> <OL class="alphaLC" start="3"> <LI><p class="outputTextNB"><strong>Regular Post-Eligibility Treatment of Income: 209(B) State.</strong></p> <p class="outputTextNB">The State uses more restrictive eligibility requirements than SSI and uses the post-eligibility rules at 42 CFR 435.735 for individuals who do not have a spouse or have a spouse who is not a community spouse as specified in §1924 of the Act. Payment for home and community-based waiver services is reduced by the amount remaining after deducting the following amounts and expenses from the waiver participant's income:</p> <OL class="romanLC" start="1"> <LI> <p class="outputTextNB underline"><strong>Allowance for the needs of the waiver participant</strong> (<em>select one</em>):</p> <div class="checkboxGroup"><label><input id="svapdxB5_3:elgIncPtcAlwType:0" type="radio" name="svapdxB5_3:elgIncPtcAlwType" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;The following standard included under the State plan</label></div> <div class="firstIndent"> <p class="outputTextNB">(<em>select one</em>):</p> <div class="checkboxGroup"><label><input id="svapdxB5_3:elgIncPtcStType209:0" type="radio" name="svapdxB5_3:elgIncPtcStType209" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;The following standard under 42 CFR &sect;435.121</label></div> <div class="firstIndent"> <p> <label id="svapdxB5_3:lblelgIncPtc121Std" for="svapdxB5_3:elgIncPtc121Std" class="outputLabel"> <span id="svapdxB5_3:lbltxtelgIncPtc121Std" class="outputTextNB em">Specify:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxB5_3:elgIncPtc121StdChrCntLbl" for="svapdxB5_3:elgIncPtc121StdChrCnt" class="outputLabel"> <span id="svapdxB5_3:elgIncPtc121StdChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxB5_3:elgIncPtc121StdChrCnt" type="text" name="svapdxB5_3:elgIncPtc121StdChrCnt" class="chrCnt" size="6" /><span id="svapdxB5_3:elgIncPtc121StdChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxB5_3:panel_elgIncPtc121Std"><textarea id="svapdxB5_3:elgIncPtc121Std" name="svapdxB5_3:elgIncPtc121Std" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="checkboxGroup"><label><input id="svapdxB5_3:elgIncPtcStType209:1" type="radio" name="svapdxB5_3:elgIncPtcStType209" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;Optional State supplement standard</label></div> <div class="checkboxGroup"><label><input id="svapdxB5_3:elgIncPtcStType209:2" type="radio" name="svapdxB5_3:elgIncPtcStType209" value="2" onclick="return callSave(this, event);" disabled="disabled" />&#160;Medically needy income standard</label></div> <div class="checkboxGroup"><label><input id="svapdxB5_3:elgIncPtcStType209:3" type="radio" name="svapdxB5_3:elgIncPtcStType209" value="3" onclick="return callSave(this, event);" disabled="disabled" />&#160;The special income level for institutionalized persons</label></div> <div class="firstIndent"> <p class="outputTextNB">(<em>select one</em>):</p> <div class="checkboxGroup"><label><input id="svapdxB5_3:elgIncPtcInstType:0" type="radio" name="svapdxB5_3:elgIncPtcInstType" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;300% of the SSI Federal Benefit Rate (FBR)</label></div> <div class="checkboxGroup"><label><input id="svapdxB5_3:elgIncPtcInstType:1" type="radio" name="svapdxB5_3:elgIncPtcInstType" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;A percentage of the FBR, which is less than 300%</label></div> <div class="firstIndent"> <p></p> <label id="svapdxB5_3:lblelgIncPtcInstPct" for="svapdxB5_3:elgIncPtcInstPct" class="outputLabel"> <span id="svapdxB5_3:lbltxtelgIncPtcInstPct" class="outputTextNB">Specify percentage:</span></label><input id="svapdxB5_3:elgIncPtcInstPct" type="text" name="svapdxB5_3:elgIncPtcInstPct" class="inputTextSmall" readonly="readonly" /> </div> <div class="checkboxGroup"><label><input id="svapdxB5_3:elgIncPtcInstType:2" type="radio" name="svapdxB5_3:elgIncPtcInstType" value="2" onclick="return callSave(this, event);" disabled="disabled" />&#160;A dollar amount which is less than 300%.</label></div> <div class="firstIndent"> <p></p> <label id="svapdxB5_3:lblelgIncPtcInstAmt" for="svapdxB5_3:elgIncPtcInstAmt" class="outputLabel"> <span id="svapdxB5_3:lbltxtelgIncPtcInstAmt" class="outputTextNB">Specify dollar amount:</span></label><input id="svapdxB5_3:elgIncPtcInstAmt" type="text" name="svapdxB5_3:elgIncPtcInstAmt" class="inputTextSmall" readonly="readonly" /> </div> <div class="noShow"><label><input id="svapdxB5_3:elgIncPtcInstType:3" type="radio" name="svapdxB5_3:elgIncPtcInstType" checked="checked" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </div> <div class="checkboxGroup"><label><input id="svapdxB5_3:elgIncPtcStType209:4" type="radio" name="svapdxB5_3:elgIncPtcStType209" value="4" onclick="return callSave(this, event);" disabled="disabled" />&#160;A percentage of the Federal poverty level</label></div> <div class="firstIndent"> <p></p> <label id="svapdxB5_3:lblelgIncPtcFedPovPct" for="svapdxB5_3:elgIncPtcFedPovPct" class="outputLabel"> <span id="svapdxB5_3:lbltxtelgIncPtcFedPovPct" class="outputTextNB">Specify percentage:</span></label><input id="svapdxB5_3:elgIncPtcFedPovPct" type="text" name="svapdxB5_3:elgIncPtcFedPovPct" class="inputTextSmall" readonly="readonly" /> </div> <div class="checkboxGroup"><label><input id="svapdxB5_3:elgIncPtcStType209:5" type="radio" name="svapdxB5_3:elgIncPtcStType209" value="5" onclick="return callSave(this, event);" disabled="disabled" />&#160;Other standard included under the State Plan</label></div> <div class="firstIndent"> <p> <label id="svapdxB5_3:lblelgIncPtcStOth" for="svapdxB5_3:elgIncPtcStOth" class="outputLabel"> <span id="svapdxB5_3:lbltxtelgIncPtcStOth" class="outputTextNB em">Specify:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxB5_3:elgIncPtcStOthChrCntLbl" for="svapdxB5_3:elgIncPtcStOthChrCnt" class="outputLabel"> <span id="svapdxB5_3:elgIncPtcStOthChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxB5_3:elgIncPtcStOthChrCnt" type="text" name="svapdxB5_3:elgIncPtcStOthChrCnt" class="chrCnt" size="6" /><span id="svapdxB5_3:elgIncPtcStOthChrCntMax" class="chrCnt"> out of 36000</span> </div> <div class="inputTextareaWA"> <span id="svapdxB5_3:panel_elgIncPtcStOth"><textarea id="svapdxB5_3:elgIncPtcStOth" name="svapdxB5_3:elgIncPtcStOth" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="noShow"><label><input id="svapdxB5_3:elgIncPtcStType209:6" type="radio" name="svapdxB5_3:elgIncPtcStType209" checked="checked" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </div> <div class="checkboxGroup"><label><input id="svapdxB5_3:elgIncPtcAlwType:1" type="radio" name="svapdxB5_3:elgIncPtcAlwType" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;The following dollar amount</label></div> <div class="firstIndent"> <p></p> <label id="svapdxB5_3:lblelgIncPtcAmt" for="svapdxB5_3:elgIncPtcAmt" class="outputLabel"> <span id="svapdxB5_3:lbltxtelgIncPtcAmt" class="outputTextNB">Specify dollar amount:</span></label><input id="svapdxB5_3:elgIncPtcAmt" type="text" name="svapdxB5_3:elgIncPtcAmt" class="inputTextSmall" readonly="readonly" /> <span class="outputTextNB"> If this amount changes, this item will be revised.</span> </div> <div class="checkboxGroup"><label><input id="svapdxB5_3:elgIncPtcAlwType:2" type="radio" name="svapdxB5_3:elgIncPtcAlwType" checked="checked" value="2" onclick="return callSave(this, event);" disabled="disabled" />&#160;The following formula is used to determine the needs allowance:</label></div> <div class="firstIndent"> <p> <label id="svapdxB5_3:lblelgIncPtcFrml" for="svapdxB5_3:elgIncPtcFrml" class="outputLabel"> <span id="svapdxB5_3:lbltxtelgIncPtcFrml" class="outputTextNB em">Specify:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxB5_3:elgIncPtcFrmlChrCntLbl" for="svapdxB5_3:elgIncPtcFrmlChrCnt" class="outputLabel"> <span id="svapdxB5_3:elgIncPtcFrmlChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxB5_3:elgIncPtcFrmlChrCnt" type="text" name="svapdxB5_3:elgIncPtcFrmlChrCnt" class="chrCnt" size="6" /><span id="svapdxB5_3:elgIncPtcFrmlChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxB5_3:panel_elgIncPtcFrml"><textarea id="svapdxB5_3:elgIncPtcFrml" name="svapdxB5_3:elgIncPtcFrml" class="inputTextarea" onkeyup="Count(this);" readonly="readonly">200% of the Federal Poverty level</textarea></span> </div> </div> <div class="checkboxGroup"><label><input id="svapdxB5_3:elgIncPtcAlwType:3" type="radio" name="svapdxB5_3:elgIncPtcAlwType" value="3" onclick="return callSave(this, event);" disabled="disabled" />&#160;Other</label></div> <div class="firstIndent"> <p> <label id="svapdxB5_3:lblelgIncPtcOth" for="svapdxB5_3:elgIncPtcOth" class="outputLabel"> <span id="svapdxB5_3:lbltxtelgIncPtcOth" class="outputTextNB em"> Specify:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxB5_3:elgIncPtcOthChrCntLbl" for="svapdxB5_3:elgIncPtcOthChrCnt" class="outputLabel"> <span id="svapdxB5_3:elgIncPtcOthChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxB5_3:elgIncPtcOthChrCnt" type="text" name="svapdxB5_3:elgIncPtcOthChrCnt" class="chrCnt" size="6" /><span id="svapdxB5_3:elgIncPtcOthChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxB5_3:panel_elgIncPtcOth"><textarea id="svapdxB5_3:elgIncPtcOth" name="svapdxB5_3:elgIncPtcOth" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="noShow"><label><input id="svapdxB5_3:elgIncPtcAlwType:4" type="radio" name="svapdxB5_3:elgIncPtcAlwType" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </LI> <LI> <p class="outputTextNB underline"><strong>Allowance for the spouse only</strong> (<em>select one</em>):</p> <div class="checkboxGroup"><label><input id="svapdxB5_3:elgIncSpoNonAlw:1" type="radio" name="svapdxB5_3:elgIncSpoNonAlw" checked="checked" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;Not Applicable</label></div> <div class="checkboxGroup"><label><input id="svapdxB5_3:elgIncSpoNonAlw:0" type="radio" name="svapdxB5_3:elgIncSpoNonAlw" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;The state provides an allowance for a spouse who does not meet the definition of a community spouse in &sect;1924 of the Act. Describe the circumstances under which this allowance is provided:</label></div> <div class="firstIndent"> <label id="svapdxB5_3:lblelgIncSpoNonAlwDscr" for="svapdxB5_3:elgIncSpoNonAlwDscr" class="outputLabel"> <span id="svapdxB5_3:lbltxtelgIncSpoNonAlwDscr" class="outputTextNB em">Specify:</span></label> <p></p> <div class="chrCntDiv"> <label id="svapdxB5_3:elgIncSpoNonAlwDscrChrCntLbl" for="svapdxB5_3:elgIncSpoNonAlwDscrChrCnt" class="outputLabel"> <span id="svapdxB5_3:elgIncSpoNonAlwDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxB5_3:elgIncSpoNonAlwDscrChrCnt" type="text" name="svapdxB5_3:elgIncSpoNonAlwDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxB5_3:elgIncSpoNonAlwDscrChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxB5_3:panel_elgIncSpoNonAlwDscr"><textarea id="svapdxB5_3:elgIncSpoNonAlwDscr" name="svapdxB5_3:elgIncSpoNonAlwDscr" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="firstIndent"> <p class="outputTextNB"><strong>Specify the amount of the allowance</strong> (<em>select one</em>):</p> <div class="checkboxGroup"><label><input id="svapdxB5_3:elgIncSpoAlwType209_2:0" type="radio" name="svapdxB5_3:elgIncSpoAlwType209_2" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;The following standard under 42 CFR &sect;435.121</label></div> <div class="firstIndent"> <p> <label id="svapdxB5_3:lblelgIncSpo121Std_2" for="svapdxB5_3:elgIncSpo121Std_2" class="outputLabel"> <span id="svapdxB5_3:lbltxtelgIncSpo121Std_2" class="outputTextNB em">Specify:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxB5_3:elgIncSpo121Std_2ChrCntLbl" for="svapdxB5_3:elgIncSpo121Std_2ChrCnt" class="outputLabel"> <span id="svapdxB5_3:elgIncSpo121Std_2ChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxB5_3:elgIncSpo121Std_2ChrCnt" type="text" name="svapdxB5_3:elgIncSpo121Std_2ChrCnt" class="chrCnt" size="6" /><span id="svapdxB5_3:elgIncSpo121Std_2ChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxB5_3:panel_elgIncSpo121Std_2"><textarea id="svapdxB5_3:elgIncSpo121Std_2" name="svapdxB5_3:elgIncSpo121Std_2" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="checkboxGroup"><label><input id="svapdxB5_3:elgIncSpoAlwType209_2:1" type="radio" name="svapdxB5_3:elgIncSpoAlwType209_2" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;Optional State supplement standard</label></div> <div class="checkboxGroup"><label><input id="svapdxB5_3:elgIncSpoAlwType209_2:2" type="radio" name="svapdxB5_3:elgIncSpoAlwType209_2" value="2" onclick="return callSave(this, event);" disabled="disabled" />&#160;Medically needy income standard</label></div> <div class="checkboxGroup"><label><input id="svapdxB5_3:elgIncSpoAlwType209_2:3" type="radio" name="svapdxB5_3:elgIncSpoAlwType209_2" value="3" onclick="return callSave(this, event);" disabled="disabled" />&#160;The following dollar amount: </label></div> <div class="firstIndent"> <p></p> <label id="svapdxB5_3:lblelgIncSpoAmt_2" for="svapdxB5_3:elgIncSpoAmt_2" class="outputLabel"> <span id="svapdxB5_3:lbltxtelgIncSpoAmt_2" class="outputTextNB">Specify dollar amount:</span></label><input id="svapdxB5_3:elgIncSpoAmt_2" type="text" name="svapdxB5_3:elgIncSpoAmt_2" class="inputTextSmall" readonly="readonly" /> <span class="outputTextNB"> If this amount changes, this item will be revised.</span> </div> <div class="checkboxGroup"><label><input id="svapdxB5_3:elgIncSpoAlwType209_2:4" type="radio" name="svapdxB5_3:elgIncSpoAlwType209_2" value="4" onclick="return callSave(this, event);" disabled="disabled" />&#160;The amount is determined using the following formula:</label></div> <div class="firstIndent"> <p> <label id="svapdxB5_3:lblelgIncSpoFrml_2" for="svapdxB5_3:elgIncSpoFrml_2" class="outputLabel"> <span id="svapdxB5_3:lbltxtelgIncSpoFrml_2" class="outputTextNB em">Specify:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxB5_3:elgIncSpoFrml_2ChrCntLbl" for="svapdxB5_3:elgIncSpoFrml_2ChrCnt" class="outputLabel"> <span id="svapdxB5_3:elgIncSpoFrml_2ChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxB5_3:elgIncSpoFrml_2ChrCnt" type="text" name="svapdxB5_3:elgIncSpoFrml_2ChrCnt" class="chrCnt" size="6" /><span id="svapdxB5_3:elgIncSpoFrml_2ChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxB5_3:panel_elgIncSpoFrml_2"><textarea id="svapdxB5_3:elgIncSpoFrml_2" name="svapdxB5_3:elgIncSpoFrml_2" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="noShow"><label><input id="svapdxB5_3:elgIncSpoAlwType209_2:6" type="radio" name="svapdxB5_3:elgIncSpoAlwType209_2" checked="checked" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </div> <div class="noShow"><label><input id="svapdxB5_3:elgIncSpoNonAlw:2" type="radio" name="svapdxB5_3:elgIncSpoNonAlw" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </LI> <LI> <p class="outputTextNB underline"><strong>Allowance for the family</strong> (<em>select one</em>):</p> <div class="checkboxGroup"><label><input id="svapdxB5_3:elgIncFamAlwType:5" type="radio" name="svapdxB5_3:elgIncFamAlwType" value="5" onclick="return callSave(this, event);" disabled="disabled" />&#160;Not Applicable (see instructions)</label></div> <div class="checkboxGroup"><label><input id="svapdxB5_3:elgIncFamAlwType:0" type="radio" name="svapdxB5_3:elgIncFamAlwType" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;AFDC need standard</label></div> <div class="checkboxGroup"><label><input id="svapdxB5_3:elgIncFamAlwType:1" type="radio" name="svapdxB5_3:elgIncFamAlwType" checked="checked" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;Medically needy income standard</label></div> <div class="checkboxGroup"><label><input id="svapdxB5_3:elgIncFamAlwType:2" type="radio" name="svapdxB5_3:elgIncFamAlwType" value="2" onclick="return callSave(this, event);" disabled="disabled" />&#160;The following dollar amount:</label></div> <div class="firstIndent"> <p></p> <label id="svapdxB5_3:lblelgIncFamAmt" for="svapdxB5_3:elgIncFamAmt" class="outputLabel"> <span id="svapdxB5_3:lbltxtelgIncFamAmt" class="outputTextNB">Specify dollar amount:</span></label><input id="svapdxB5_3:elgIncFamAmt" type="text" name="svapdxB5_3:elgIncFamAmt" class="inputTextSmall" readonly="readonly" /> <span class="outputTextNB"> The amount specified cannot exceed the higher of the need standard for a family of the same size used to determine eligibility under the State's approved AFDC plan or the medically needy income standard established under 42 CFR §435.811 for a family of the same size. If this amount changes, this item will be revised.</span> </div> <div class="checkboxGroup"><label><input id="svapdxB5_3:elgIncFamAlwType:3" type="radio" name="svapdxB5_3:elgIncFamAlwType" value="3" onclick="return callSave(this, event);" disabled="disabled" />&#160;The amount is determined using the following formula:</label></div> <div class="firstIndent"> <p> <label id="svapdxB5_3:lblelgIncFamFrml" for="svapdxB5_3:elgIncFamFrml" class="outputLabel"> <span id="svapdxB5_3:lbltxtelgIncFamFrml" class="outputTextNB em">Specify:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxB5_3:elgIncFamFrmlChrCntLbl" for="svapdxB5_3:elgIncFamFrmlChrCnt" class="outputLabel"> <span id="svapdxB5_3:elgIncFamFrmlChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxB5_3:elgIncFamFrmlChrCnt" type="text" name="svapdxB5_3:elgIncFamFrmlChrCnt" class="chrCnt" size="6" /><span id="svapdxB5_3:elgIncFamFrmlChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxB5_3:panel_elgIncFamFrml"><textarea id="svapdxB5_3:elgIncFamFrml" name="svapdxB5_3:elgIncFamFrml" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="checkboxGroup"><label><input id="svapdxB5_3:elgIncFamAlwType:4" type="radio" name="svapdxB5_3:elgIncFamAlwType" value="4" onclick="return callSave(this, event);" disabled="disabled" />&#160;Other</label></div> <div class="firstIndent"> <label id="svapdxB5_3:lblelgIncFamOthDscr" for="svapdxB5_3:elgIncFamOthDscr" class="outputLabel"> <span id="svapdxB5_3:lbltxtelgIncFamOthDscr" class="outputTextNB em">Specify:</span></label> <p></p> <div class="chrCntDiv"> <label id="svapdxB5_3:elgIncFamOthDscrChrCntLbl" for="svapdxB5_3:elgIncFamOthDscrChrCnt" class="outputLabel"> <span id="svapdxB5_3:elgIncFamOthDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxB5_3:elgIncFamOthDscrChrCnt" type="text" name="svapdxB5_3:elgIncFamOthDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxB5_3:elgIncFamOthDscrChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxB5_3:panel_elgIncFamOthDscr"><textarea id="svapdxB5_3:elgIncFamOthDscr" name="svapdxB5_3:elgIncFamOthDscr" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="noShow"><label><input id="svapdxB5_3:elgIncFamAlwType:6" type="radio" name="svapdxB5_3:elgIncFamAlwType" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </LI> <li> <p class="outputTextNB underline"><strong>Amounts for incurred medical or remedial care expenses not subject to payment by a third party, specified in 42 §CFR 435.726:</strong></p> <div> <ol class="alphaLC" start="1"> <li class="outputTextNB">Health insurance premiums, deductibles and co-insurance charges</li> <li class="outputTextNB">Necessary medical or remedial care expenses recognized under State law but not covered under the State's Medicaid plan, subject to reasonable limits that the State may establish on the amounts of these expenses.</li> </ol> </div> <p class="outputTextNB">Select one:</p> <div class="checkboxGroup"> <label><input id="svapdxB5_3:elgIncOthType:2" type="radio" name="svapdxB5_3:elgIncOthType" value="2" onclick="return callSave(this, event);" disabled="disabled" />&#160;Not Applicable (see instructions)</label><span id="svapdxB5_3:elgIncOthType_2_instr" class="outputTextNB em">Note: If the State protects the maximum amount for the waiver participant, not applicable must be selected.</span> </div> <div class="checkboxGroup"><label><input id="svapdxB5_3:elgIncOthType:0" type="radio" name="svapdxB5_3:elgIncOthType" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;The State does not establish reasonable limits.</label></div> <div class="checkboxGroup"><label><input id="svapdxB5_3:elgIncOthType:1" type="radio" name="svapdxB5_3:elgIncOthType" checked="checked" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;The State establishes the following reasonable limits </label></div> <div class="firstIndent"> <p> <label id="svapdxB5_3:lblelgIncOthLimit" for="svapdxB5_3:elgIncOthLimit" class="outputLabel"> <span id="svapdxB5_3:lbltxtelgIncOthLimit" class="outputTextNB em">Specify:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxB5_3:elgIncOthLimitChrCntLbl" for="svapdxB5_3:elgIncOthLimitChrCnt" class="outputLabel"> <span id="svapdxB5_3:elgIncOthLimitChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxB5_3:elgIncOthLimitChrCnt" type="text" name="svapdxB5_3:elgIncOthLimitChrCnt" class="chrCnt" size="6" /><span id="svapdxB5_3:elgIncOthLimitChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxB5_3:panel_elgIncOthLimit"><textarea id="svapdxB5_3:elgIncOthLimit" name="svapdxB5_3:elgIncOthLimit" class="inputTextarea" onkeyup="Count(this);" readonly="readonly">The deduction for medical and remedial care expenses that were incurred as a result of imposition of a transfer of assets penalty is limited to zero.</textarea></span> </div> </div> <div class="noShow"><label><input id="svapdxB5_3:elgIncOthType:3" type="radio" name="svapdxB5_3:elgIncOthType" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </li> </OL> </LI> </OL> <H2 id="pageTitle">Appendix B: Participant Access and Eligibility</H2> <H3 id="pageSubTitle">B-5: Post-Eligibility Treatment of Income <SPAN id="pageNumber">(4 of 7)</SPAN></H3> <div class="pph"> <span id="svapdxB5_4:newInstr2" class="outputTextNB em">Note: The following selections apply for the time periods before January 1, 2014 or after December 31, 2018.</span> </div> <OL class="alphaLC" start="4"> <LI> <p> <span id="svapdxB5_4:b5dtitle" class="outputText">Post-Eligibility Treatment of Income Using Spousal Impoverishment Rules</span> </p> <p class="outputTextNB"> <span id="svapdxB5_4:b5ddesc" class="outputTextNB">The State uses the post-eligibility rules of &sect;1924(d) of the Act (spousal impoverishment protection) to determine the contribution of a participant with a community spouse toward the cost of home and community-based care if it determines the individual's eligibility under &sect;1924 of the Act. There is deducted from the participant's monthly income a personal needs allowance (as specified below), a community spouse's allowance and a family allowance as specified in the State Medicaid Plan. The State must also protect amounts for incurred expenses for medical or remedial care (as specified below).</span> </p> <OL class="romanLC" start="1"> <LI> <p class="outputText">Allowance for the personal needs of the waiver participant </p> <span class="outputTextNB"> (<em>select one</em>):</span> <div class="checkboxGroup"><label><input id="svapdxB5_4:elgInc1924dAlwType:0" type="radio" name="svapdxB5_4:elgInc1924dAlwType" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;SSI standard</label></div> <div class="checkboxGroup"><label><input id="svapdxB5_4:elgInc1924dAlwType:1" type="radio" name="svapdxB5_4:elgInc1924dAlwType" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;Optional State supplement standard</label></div> <div class="checkboxGroup"><label><input id="svapdxB5_4:elgInc1924dAlwType:2" type="radio" name="svapdxB5_4:elgInc1924dAlwType" value="2" onclick="return callSave(this, event);" disabled="disabled" />&#160;Medically needy income standard</label></div> <div class="checkboxGroup"><label><input id="svapdxB5_4:elgInc1924dAlwType:3" type="radio" name="svapdxB5_4:elgInc1924dAlwType" value="3" onclick="return callSave(this, event);" disabled="disabled" />&#160;The special income level for institutionalized persons</label></div> <div class="checkboxGroup"><label><input id="svapdxB5_4:elgInc1924dAlwType:4" type="radio" name="svapdxB5_4:elgInc1924dAlwType" checked="checked" value="4" onclick="return callSave(this, event);" disabled="disabled" />&#160;A percentage of the Federal poverty level</label></div> <div class="firstIndent"> <p></p> <label id="svapdxB5_4:lblelgInc1924dInstPct" for="svapdxB5_4:elgInc1924dInstPct" class="outputLabel"> <span id="svapdxB5_4:lbltxtelgInc1924dInstPct" class="outputTextNB">Specify percentage:</span></label><input id="svapdxB5_4:elgInc1924dInstPct" type="text" name="svapdxB5_4:elgInc1924dInstPct" value="200" class="inputTextSmall" readonly="readonly" /> </div> <div class="checkboxGroup"><label><input id="svapdxB5_4:elgInc1924dAlwType:5" type="radio" name="svapdxB5_4:elgInc1924dAlwType" value="5" onclick="return callSave(this, event);" disabled="disabled" />&#160;The following dollar amount:</label></div> <div class="firstIndent"> <p></p> <label id="svapdxB5_4:lblelgInc1924dAmt" for="svapdxB5_4:elgInc1924dAmt" class="outputLabel"> <span id="svapdxB5_4:lbltxtelgInc1924dAmt" class="outputTextNB">Specify dollar amount:</span></label><input id="svapdxB5_4:elgInc1924dAmt" type="text" name="svapdxB5_4:elgInc1924dAmt" class="inputTextSmall" readonly="readonly" /> <span class="outputTextNB">If this amount changes, this item will be revised</span> </div> <div class="checkboxGroup"><label><input id="svapdxB5_4:elgInc1924dAlwType:6" type="radio" name="svapdxB5_4:elgInc1924dAlwType" value="6" onclick="return callSave(this, event);" disabled="disabled" />&#160;The following formula is used to determine the needs allowance:</label></div> <div class="firstIndent"> <p> <label id="svapdxB5_4:lblelgInc1924dFrml" for="svapdxB5_4:elgInc1924dFrml" class="outputLabel"> <span id="svapdxB5_4:lbltxtelgInc1924dFrml" class="outputTextNB em">Specify formula:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxB5_4:elgInc1924dFrmlChrCntLbl" for="svapdxB5_4:elgInc1924dFrmlChrCnt" class="outputLabel"> <span id="svapdxB5_4:elgInc1924dFrmlChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxB5_4:elgInc1924dFrmlChrCnt" type="text" name="svapdxB5_4:elgInc1924dFrmlChrCnt" class="chrCnt" size="6" /><span id="svapdxB5_4:elgInc1924dFrmlChrCntMax" class="chrCnt"> out of 4000</span> </div> <div class="inputTextareaWA"> <span id="svapdxB5_4:panel_elgInc1924dFrml"><textarea id="svapdxB5_4:elgInc1924dFrml" name="svapdxB5_4:elgInc1924dFrml" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="checkboxGroup"><label><input id="svapdxB5_4:elgInc1924dAlwType:7" type="radio" name="svapdxB5_4:elgInc1924dAlwType" value="7" onclick="return callSave(this, event);" disabled="disabled" />&#160;Other</label></div> <div class="firstIndent"> <p> <label id="svapdxB5_4:lblelgInc1924dOthDscr" for="svapdxB5_4:elgInc1924dOthDscr" class="outputLabel"> <span id="svapdxB5_4:lbltxtelgInc1924dOthDscr" class="outputTextNB em">Specify:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxB5_4:elgInc1924dOthDscrChrCntLbl" for="svapdxB5_4:elgInc1924dOthDscrChrCnt" class="outputLabel"> <span id="svapdxB5_4:elgInc1924dOthDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxB5_4:elgInc1924dOthDscrChrCnt" type="text" name="svapdxB5_4:elgInc1924dOthDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxB5_4:elgInc1924dOthDscrChrCntMax" class="chrCnt"> out of 36000</span> </div> <div class="inputTextareaWA"> <span id="svapdxB5_4:panel_elgInc1924dOthDscr"><textarea id="svapdxB5_4:elgInc1924dOthDscr" name="svapdxB5_4:elgInc1924dOthDscr" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="noShow"><label><input id="svapdxB5_4:elgInc1924dAlwType:8" type="radio" name="svapdxB5_4:elgInc1924dAlwType" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </LI> <LI> <p class="outputText"> If the allowance for the personal needs of a waiver participant with a community spouse is different from the amount used for the individual's maintenance allowance under 42 CFR §435.726 or 42 CFR §435.735, explain why this amount is reasonable to meet the individual's maintenance needs in the community. </p> <p class="outputTextNB">Select one:</p> <div class="checkboxGroup"><label><input id="svapdxB5_4:elgInc1924dDiffType:0" type="radio" name="svapdxB5_4:elgInc1924dDiffType" checked="checked" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;Allowance is the same</label></div> <div class="checkboxGroup"><label><input id="svapdxB5_4:elgInc1924dDiffType:1" type="radio" name="svapdxB5_4:elgInc1924dDiffType" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;Allowance is different.</label></div> <div class="firstIndent"> <p> <label id="svapdxB5_4:lblelgInc1924dDiffDscr" for="svapdxB5_4:elgInc1924dDiffDscr" class="outputLabel"> <span id="svapdxB5_4:lbltxtelgInc1924dDiffDscr" class="outputTextNB em">Explanation of difference:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxB5_4:elgInc1924dDiffDscrChrCntLbl" for="svapdxB5_4:elgInc1924dDiffDscrChrCnt" class="outputLabel"> <span id="svapdxB5_4:elgInc1924dDiffDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxB5_4:elgInc1924dDiffDscrChrCnt" type="text" name="svapdxB5_4:elgInc1924dDiffDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxB5_4:elgInc1924dDiffDscrChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxB5_4:panel_elgInc1924dDiffDscr"><textarea id="svapdxB5_4:elgInc1924dDiffDscr" name="svapdxB5_4:elgInc1924dDiffDscr" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="noShow"><label><input id="svapdxB5_4:elgInc1924dDiffType:2" type="radio" name="svapdxB5_4:elgInc1924dDiffType" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </LI> <li> <p class="outputTextNB"><strong>Amounts for incurred medical or remedial care expenses not subject to payment by a third party, specified in 42 CFR §435.726:</strong></p> <div> <ol class="alphaLC" start="1"> <li class="outputTextNB">Health insurance premiums, deductibles and co-insurance charges</li> <li class="outputTextNB">Necessary medical or remedial care expenses recognized under State law but not covered under the State's Medicaid plan, subject to reasonable limits that the State may establish on the amounts of these expenses.</li> </ol> </div> <p class="outputTextNB">Select one:</p> <div class="checkboxGroup"><label><input id="svapdxB5_4:elgInc1924dOthType:2" type="radio" name="svapdxB5_4:elgInc1924dOthType" value="2" onclick="return callSave(this, event);" disabled="disabled" />&#160;Not Applicable (see instructions)</label><span id="svapdxB5_4:elgInc1924dOthType_2_instr" class="outputTextNB em">Note: If the State protects the maximum amount for the waiver participant, not applicable must be selected.</span> </div> <div class="checkboxGroup"><label><input id="svapdxB5_4:elgInc1924dOthType:0" type="radio" name="svapdxB5_4:elgInc1924dOthType" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;The State does not establish reasonable limits.</label></div> <div class="checkboxGroup"><label><input id="svapdxB5_4:elgInc1924dOthType:1" type="radio" name="svapdxB5_4:elgInc1924dOthType" checked="checked" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;The State uses the same reasonable limits as are used for regular (non-spousal) post-eligibility.</label></div> <div class="noShow"><label><input id="svapdxB5_4:elgInc1924dOthType:3" type="radio" name="svapdxB5_4:elgInc1924dOthType" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </li> </OL> </LI> </OL> <H2 id="pageTitle">Appendix B: Participant Access and Eligibility</H2> <H3 id="pageSubTitle">B-5: Post-Eligibility Treatment of Income <SPAN id="pageNumber">(5 of 7)</SPAN></H3> <div class="pph"> <span id="svapdxB5_5:newInstr2" class="outputTextNB em">Note: The following selections apply for the five-year period beginning January 1, 2014.</span> </div> <OL class="alphaLC" start="5"> <LI> <p class="outputTextNB"> <span id="svapdxB5_5:questionB5eTitle1" class="outputText">Regular Post-Eligibility Treatment of Income: </span><span id="svapdxB5_5:questionB5eTitle4" class="outputText">SSI State or &sect;1634 State</span><span id="svapdxB5_5:questionB5eTitle5" class="outputText"> - 2014 through 2018.</span> </p> <div> <p class="pph underline bld"> Answers provided in Appendix B-4 indicate that you do not need to complete this section and therefore this section is not visible. </p> </div> </LI> </OL> <H2 id="pageTitle">Appendix B: Participant Access and Eligibility</H2> <H3 id="pageSubTitle">B-5: Post-Eligibility Treatment of Income <SPAN id="pageNumber">(6 of 7)</SPAN></H3> <div class="pph"> <span id="svapdxB5_6:newInstr2" class="outputTextNB em">Note: The following selections apply for the five-year period beginning January 1, 2014.</span> </div> <OL class="alphaLC" start="6"> <LI><p class="outputTextNB"><strong>Regular Post-Eligibility Treatment of Income: 209(B) State - 2014 through 2018.</strong></p> <div> <p class="pph underline bld"> Answers provided in Appendix B-5-a indicate the selections in B-5-c also apply to B-5-f. </p> </div> </LI> </OL> <H2 id="pageTitle">Appendix B: Participant Access and Eligibility</H2> <H3 id="pageSubTitle">B-5: Post-Eligibility Treatment of Income <SPAN id="pageNumber">(7 of 7)</SPAN></H3> <div class="pph"> <span id="svapdxB5_7:newInstr2" class="outputTextNB em">Note: The following selections apply for the five-year period beginning January 1, 2014.</span> </div> <OL class="alphaLC" start="7"> <LI> <p> <span id="svapdxB5_7:b5dtitle" class="outputText">Post-Eligibility Treatment of Income Using Spousal Impoverishment Rules - 2014 through 2018.</span> </p> <p class="outputTextNB"> <span id="svapdxB5_7:b5ddesc" class="outputTextNB">The State uses the post-eligibility rules of &sect;1924(d) of the Act (spousal impoverishment protection) to determine the contribution of a participant with a community spouse toward the cost of home and community-based care. There is deducted from the participant's monthly income a personal needs allowance (as specified below), a community spouse's allowance and a family allowance as specified in the State Medicaid Plan. The State must also protect amounts for incurred expenses for medical or remedial care (as specified below).</span> </p> <div class="pph underline bld"> <span id="svapdxB5_7:b5ancb" class="outputText">Answers provided in Appendix B-5-a indicate the selections in B-5-d also apply to B-5-g.</span> </div> </LI> </OL> <H2 id="pageTitle">Appendix B: Participant Access and Eligibility</H2> <H3 id="pageSubTitle">B-6: Evaluation/Reevaluation of Level of Care</H3> <div class="outputTextNB"> <em>As specified in 42 CFR §441.302(c), the State provides for an evaluation (and periodic reevaluations) of the need for the level(s) of care specified for this waiver, when there is a reasonable indication that an individual may need such services in the near future (one month or less), but for the availability of home and community-based waiver services.</em> </div> <OL class="alphaLC" start="1"> <LI> <p class="outputTextNB"> <strong>Reasonable Indication of Need for Services.</strong> In order for an individual to be determined to need waiver services, an individual must require: (a) the provision of at least one waiver service, as documented in the service plan, <u>and</u> (b) the provision of waiver services at least monthly or, if the need for services is less than monthly, the participant requires regular monthly monitoring which must be documented in the service plan. Specify the State's policies concerning the reasonable indication of the need for services: </p> <OL class="romanLC" start="1"> <LI> <p class="outputText">Minimum number of services.</p> <p></p> <label id="svapdxB6_1:lblelgEvalSvcMinQty" for="svapdxB6_1:elgEvalSvcMinQty" class="outputLabel"> <span id="svapdxB6_1:lbltxtelgEvalSvcMinQty" class="outputTextNB">The minimum number of waiver services (one or more) that an individual must require in order to be determined to need waiver services is:</span></label><input id="svapdxB6_1:elgEvalSvcMinQty" type="text" name="svapdxB6_1:elgEvalSvcMinQty" value="1" class="inputTextSmall" readonly="readonly" /> </LI> <LI> <div> <span class="outputText">Frequency of services.</span> <span class="outputTextNB"> The State requires (select one):</span> </div> <div class="checkboxGroup"><label><input id="svapdxB6_1:elgEvalSvcFreq:0" type="radio" name="svapdxB6_1:elgEvalSvcFreq" checked="checked" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;The provision of waiver services at least monthly</label></div> <div class="checkboxGroup"><label><input id="svapdxB6_1:elgEvalSvcFreq:1" type="radio" name="svapdxB6_1:elgEvalSvcFreq" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;Monthly monitoring of the individual when services are furnished on a less than monthly basis</label></div> <div class="firstIndent"> <p> <label id="svapdxB6_1:lblelgEvalSvcMinFreq" for="svapdxB6_1:elgEvalSvcMinFreq" class="outputLabel"> <span id="svapdxB6_1:lbltxtelgEvalSvcMinFreq" class="outputTextNB em">If the State also requires a minimum frequency for the provision of waiver services other than monthly (e.g., quarterly), specify the frequency:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxB6_1:elgEvalSvcMinFreqChrCntLbl" for="svapdxB6_1:elgEvalSvcMinFreqChrCnt" class="outputLabel"> <span id="svapdxB6_1:elgEvalSvcMinFreqChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxB6_1:elgEvalSvcMinFreqChrCnt" type="text" name="svapdxB6_1:elgEvalSvcMinFreqChrCnt" class="chrCnt" size="6" /><span id="svapdxB6_1:elgEvalSvcMinFreqChrCntMax" class="chrCnt"> out of 4000</span> </div> <div class="inputTextareaWA"> <span id="svapdxB6_1:panel_elgEvalSvcMinFreq"><textarea id="svapdxB6_1:elgEvalSvcMinFreq" name="svapdxB6_1:elgEvalSvcMinFreq" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="noShow"><label><input id="svapdxB6_1:elgEvalSvcFreq:2" type="radio" name="svapdxB6_1:elgEvalSvcFreq" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </LI> </OL> </LI> <LI> <div class="outputTextNB"> <strong>Responsibility for Performing Evaluations and Reevaluations.</strong> Level of care evaluations and reevaluations are performed (<em>select one</em>): </div> <div class="checkboxGroup"><label><input id="svapdxB6_1:elgEvalRespType:0" type="radio" name="svapdxB6_1:elgEvalRespType" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;Directly by the Medicaid agency </label></div> <div class="checkboxGroup"><label><input id="svapdxB6_1:elgEvalRespType:1" type="radio" name="svapdxB6_1:elgEvalRespType" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;By the operating agency specified in Appendix A</label></div> <div class="checkboxGroup"><label><input id="svapdxB6_1:elgEvalRespType:2" type="radio" name="svapdxB6_1:elgEvalRespType" checked="checked" value="2" onclick="return callSave(this, event);" disabled="disabled" />&#160;By an entity under contract with the Medicaid agency.</label></div> <div class="firstIndent"> <p> <label id="svapdxB6_1:lblelgEvalRespContrEnt" for="svapdxB6_1:elgEvalRespContrEnt" class="outputLabel"> <span id="svapdxB6_1:lbltxtelgEvalRespContrEnt" class="outputTextNB em">Specify the entity:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxB6_1:elgEvalRespContrEntChrCntLbl" for="svapdxB6_1:elgEvalRespContrEntChrCnt" class="outputLabel"> <span id="svapdxB6_1:elgEvalRespContrEntChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxB6_1:elgEvalRespContrEntChrCnt" type="text" name="svapdxB6_1:elgEvalRespContrEntChrCnt" class="chrCnt" size="6" /><span id="svapdxB6_1:elgEvalRespContrEntChrCntMax" class="chrCnt"> out of 4000</span> </div> <div class="inputTextareaWA"> <span id="svapdxB6_1:panel_elgEvalRespContrEnt"><textarea id="svapdxB6_1:elgEvalRespContrEnt" name="svapdxB6_1:elgEvalRespContrEnt" class="inputTextarea" onkeyup="Count(this);" readonly="readonly">Department staff do the initial level of care evaluation and this is confirmed by the care manager at assessment and reassessment.</textarea></span> </div> </div> <div class="checkboxGroup"> <label><input id="svapdxB6_1:elgEvalRespType:3" type="radio" name="svapdxB6_1:elgEvalRespType" value="3" onclick="return callSave(this, event);" disabled="disabled" />&#160;Other</label></div> <div class="firstIndent"> <label id="svapdxB6_1:lblelgEvalRespOthEntDscr" for="svapdxB6_1:elgEvalRespOthEntDscr" class="outputLabel"> <span id="svapdxB6_1:lbltxtelgEvalRespOthEntDscr" class="outputTextNB em">Specify:</span></label> <p></p> <div class="chrCntDiv"> <label id="svapdxB6_1:elgEvalRespOthEntDscrChrCntLbl" for="svapdxB6_1:elgEvalRespOthEntDscrChrCnt" class="outputLabel"> <span id="svapdxB6_1:elgEvalRespOthEntDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxB6_1:elgEvalRespOthEntDscrChrCnt" type="text" name="svapdxB6_1:elgEvalRespOthEntDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxB6_1:elgEvalRespOthEntDscrChrCntMax" class="chrCnt"> out of 4000</span> </div> <div class="inputTextareaWA"> <span id="svapdxB6_1:panel_elgEvalRespOthEntDscr"><textarea id="svapdxB6_1:elgEvalRespOthEntDscr" name="svapdxB6_1:elgEvalRespOthEntDscr" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="noShow"><label><input id="svapdxB6_1:elgEvalRespType:4" type="radio" name="svapdxB6_1:elgEvalRespType" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </LI> <LI> <div class="outputTextNB"> <strong>Qualifications of Individuals Performing Initial Evaluation:</strong> <label id="svapdxB6_1:lblelgEvalIndvQualDscr" for="svapdxB6_1:elgEvalIndvQualDscr" class="outputLabel"> <span id="svapdxB6_1:lbltxtelgEvalIndvQualDscr" class="outputTextNB">Per 42 CFR &sect;441.303(c)(1), specify the educational/professional qualifications of individuals who perform the initial evaluation of level of care for waiver applicants:</span></label> <p></p> </div> <div class="chrCntDiv"> <label id="svapdxB6_1:elgEvalIndvQualDscrChrCntLbl" for="svapdxB6_1:elgEvalIndvQualDscrChrCnt" class="outputLabel"> <span id="svapdxB6_1:elgEvalIndvQualDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxB6_1:elgEvalIndvQualDscrChrCnt" type="text" name="svapdxB6_1:elgEvalIndvQualDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxB6_1:elgEvalIndvQualDscrChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxB6_1:panel_elgEvalIndvQualDscr"><textarea id="svapdxB6_1:elgEvalIndvQualDscr" name="svapdxB6_1:elgEvalIndvQualDscr" class="inputTextarea15" onkeyup="Count(this);" readonly="readonly">Alternate Care Unit staff that conduct the initial level of care evaluations are either Utilization Review Nurses or Social Workers with experience in long term care. The care manager who conducts the assessments and reassessments and develops care plans shall be either a registered nurse licensed in the State where care management services are provided or a social services worker who is a graduate of an accredited four-year college or university. The nurse or social services worker shall have a minimum of two years of experience in health care or human services. A bachelor's degree in nursing, health, social work, gerontology or a related field may be substituted for one year of experience. Care managers shall have the following additional qualifications: 1.demonstrated interviewing skills which include the professional judgment to probe as necessary to uncover underlying concerns of the applicant; 2.demonstrated ability to establish and maintain empathetic relationships; 3.experience in conducting social and health assessments; 4.knowledge of human behavior, family/caregiver dynamics, human development and disabilities; 5.awareness of community resources and services; 6.the ability to understand and apply complex service reimbursement issues; and 7. the ability to evaluate, negotiate and plan for the costs of care options. 8.Care management supervisors shall meet all the qualifications of a care manager plus have demonstrated supervisory ability, and at least one year of specific experience in conducting assessments, developing care plans and monitoring home and community-based services.</textarea></span> </div> </LI> <LI> <div class="outputTextNB"> <strong>Level of Care Criteria.</strong> <label id="svapdxB6_1:lblelgEvalLOCCrit" for="svapdxB6_1:elgEvalLOCCrit" class="outputLabel"> <span id="svapdxB6_1:lbltxtelgEvalLOCCrit" class="outputTextNB">Fully specify the level of care criteria that are used to evaluate and reevaluate whether an individual needs services through the waiver and that serve as the basis of the State's level of care instrument/tool. Specify the level of care instrument/tool that is employed. State laws, regulations, and policies concerning level of care criteria and the level of care instrument/tool are available to CMS upon request through the Medicaid agency or the operating agency (if applicable), including the instrument/tool utilized.</span></label> <p></p> </div> <div class="chrCntDiv"> <label id="svapdxB6_1:elgEvalLOCCritChrCntLbl" for="svapdxB6_1:elgEvalLOCCritChrCnt" class="outputLabel"> <span id="svapdxB6_1:elgEvalLOCCritChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxB6_1:elgEvalLOCCritChrCnt" type="text" name="svapdxB6_1:elgEvalLOCCritChrCnt" class="chrCnt" size="6" /><span id="svapdxB6_1:elgEvalLOCCritChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxB6_1:panel_elgEvalLOCCrit"><textarea id="svapdxB6_1:elgEvalLOCCrit" name="svapdxB6_1:elgEvalLOCCrit" class="inputTextarea15" onkeyup="Count(this);" readonly="readonly">The Department conducts level of care assessments to evaluate and reevaluate whether an individual needs services through the waiver that otherwise would require an institutional level of care. The level of care assessment is based on information obtained directly from the individual during a home visit, and a medical report from the consumer's physician. As a means to guide this level of care assessment, Connecticut Department of Social Services utilizes form W-1034 Level of Care Determination: PCA and ABI Waiver Program” in accordance with Connecticut General Statutes 17b-262-589a, the Connecticut Department of Social Services PCA Regulations and the Connecticut Department of Social Services PCA Desk Guide. Level of Care is determined based on the consumer'’s Activity of Daily Living needs; Bathing, Dressing, Transferring, Toileting, and Feeding requiring physical assistance. For the PCA Waiver, two (2) or more ADL’s needing physical assistance is required to meet Nursing Facility level of care.</textarea></span> </div> </LI> <LI> <div class="outputTextNB"> <strong>Level of Care Instrument(s).</strong> Per 42 CFR §441.303(c)(2), indicate whether the instrument/tool used to evaluate level of care for the waiver differs from the instrument/tool used to evaluate institutional level of care <em>(select one)</em>: </div> <div class="checkboxGroup"><label><input id="svapdxB6_1:elgEvalLOCInstType:0" type="radio" name="svapdxB6_1:elgEvalLOCInstType" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;The same instrument is used in determining the level of care for the waiver and for institutional care under the State Plan.</label></div> <div class="checkboxGroup"><label><input id="svapdxB6_1:elgEvalLOCInstType:1" type="radio" name="svapdxB6_1:elgEvalLOCInstType" checked="checked" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;A different instrument is used to determine the level of care for the waiver than for institutional care under the State plan.</label></div> <div class="firstIndent"> <p> <label id="svapdxB6_1:lblelgEvalLOCInstOthDscr" for="svapdxB6_1:elgEvalLOCInstOthDscr" class="outputLabel"> <span id="svapdxB6_1:lbltxtelgEvalLOCInstOthDscr" class="outputTextNB">Describe how and why this instrument differs from the form used to evaluate institutional level of care and explain how the outcome of the determination is reliable, valid, and fully comparable.</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxB6_1:elgEvalLOCInstOthDscrChrCntLbl" for="svapdxB6_1:elgEvalLOCInstOthDscrChrCnt" class="outputLabel"> <span id="svapdxB6_1:elgEvalLOCInstOthDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxB6_1:elgEvalLOCInstOthDscrChrCnt" type="text" name="svapdxB6_1:elgEvalLOCInstOthDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxB6_1:elgEvalLOCInstOthDscrChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxB6_1:panel_elgEvalLOCInstOthDscr"><textarea id="svapdxB6_1:elgEvalLOCInstOthDscr" name="svapdxB6_1:elgEvalLOCInstOthDscr" class="inputTextarea15" onkeyup="Count(this);" readonly="readonly">Institutional Long Term Care placement is facilitated through a level of care instrument that includes the following elements: - Identifying information - Patient care information (pertinent history, diagnoses, and problems) and plan of care (includes treatment diet, and activity permitted) -• Orders such as medications, allergies, therapeutic goals, level of care (e.g. Acute Hospitalization, Chronic Hospital, Nursing Facility). The Assessment for the PCA Waiver utilizes a more structured assessment tool because it is administered by care managers. The instrument utilized for the PCA Waiver differs from the standard form for institutional care but yields reliable results as it is based on the outcome of the DSS assessment. This document provides the framework to assess the following: - Environment -• Health - Life Planning - Behavioral/Cognitive Issues - Communication - Risk factors and a functional assessment - Support system - Environment Workers then use the Level of Care Determination Form (Form W-1034) to assign a level of care. This form addresses Activities of Daily Living (ADLs) and the data gathered from the assessment to select a level of care that is defined on the assessment form for easy reference. The Social Work Supervisor and then Central Office Staff, and if needed the PCA Program Manager, review these results for final approval.</textarea></span> </div> </div> <div class="noShow"><label><input id="svapdxB6_1:elgEvalLOCInstType:2" type="radio" name="svapdxB6_1:elgEvalLOCInstType" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </LI> <LI> <div class="outputTextNB"> <strong>Process for Level of Care Evaluation/Reevaluation:</strong> <label id="svapdxB6_1:lblelgRevalDscr" for="svapdxB6_1:elgRevalDscr" class="outputLabel"> <span id="svapdxB6_1:lbltxtelgRevalDscr" class="outputTextNB">Per 42 CFR &sect;441.303(c)(1), describe the process for evaluating waiver applicants for their need for the level of care under the waiver. If the reevaluation process differs from the evaluation process, describe the differences:</span></label> <p></p> </div> <div class="chrCntDiv"> <label id="svapdxB6_1:elgRevalDscrChrCntLbl" for="svapdxB6_1:elgRevalDscrChrCnt" class="outputLabel"> <span id="svapdxB6_1:elgRevalDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxB6_1:elgRevalDscrChrCnt" type="text" name="svapdxB6_1:elgRevalDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxB6_1:elgRevalDscrChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxB6_1:panel_elgRevalDscr"><textarea id="svapdxB6_1:elgRevalDscr" name="svapdxB6_1:elgRevalDscr" class="inputTextarea15" onkeyup="Count(this);" readonly="readonly">For the purposes of determining level of care, an Alternate Care Unit staff member (nurse or social worker) performs a level of care screening evaluation of each applicant. Confirmation of the level of care is determined by information gathered for the evaluation/revaluation during face-to-face interviews and includes a thorough evaluation of the client's individual circumstances. The level of care determination form (W-1034) is used to summarize this information and confirm level of care. The reevaluation process is the same as the evaluation process.</textarea></span> </div> </LI> <LI> <div class="outputTextNB"> <strong>Reevaluation Schedule.</strong> Per 42 CFR §441.303(c)(4), reevaluations of the level of care required by a participant are conducted no less frequently than annually according to the following schedule <em>(select one)</em>: </div> <div class="checkboxGroup"><label><input id="svapdxB6_1:elgRevalSchType:0" type="radio" name="svapdxB6_1:elgRevalSchType" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;Every three months</label></div> <div class="checkboxGroup"><label><input id="svapdxB6_1:elgRevalSchType:1" type="radio" name="svapdxB6_1:elgRevalSchType" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;Every six months</label></div> <div class="checkboxGroup"><label><input id="svapdxB6_1:elgRevalSchType:2" type="radio" name="svapdxB6_1:elgRevalSchType" checked="checked" value="2" onclick="return 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out of 4000</span> </div> <div class="inputTextareaWA"> <span id="svapdxB6_1:panel_elgRevalSchOthDscr"><textarea id="svapdxB6_1:elgRevalSchOthDscr" name="svapdxB6_1:elgRevalSchOthDscr" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="noShow"><label><input id="svapdxB6_1:elgRevalSchType:4" type="radio" name="svapdxB6_1:elgRevalSchType" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </LI> <LI> <div class="outputTextNB"> <strong>Qualifications of Individuals Who Perform Reevaluations.</strong> Specify the qualifications of individuals who perform reevaluations <em>(select one)</em>: </div> <div class="checkboxGroup"> <label><input id="svapdxB6_1:elgRevalIndvQualDscr:0" type="radio" name="svapdxB6_1:elgRevalIndvQualDscr" checked="checked" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;The qualifications of individuals who perform reevaluations are the same as individuals who perform initial evaluations.</label> </div> <div class="checkboxGroup"><label><input id="svapdxB6_1:elgRevalIndvQualDscr:1" type="radio" name="svapdxB6_1:elgRevalIndvQualDscr" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;The qualifications are different.</label></div> <div class="firstIndent"> <label id="svapdxB6_1:lblelgRevalIndvQualOthDscr" for="svapdxB6_1:elgRevalIndvQualOthDscr" class="outputLabel"> <span id="svapdxB6_1:lbltxtelgRevalIndvQualOthDscr" class="outputTextNB em">Specify the qualifications:</span></label> <p></p> <div class="chrCntDiv"> <label id="svapdxB6_1:elgRevalIndvQualOthDscrChrCntLbl" for="svapdxB6_1:elgRevalIndvQualOthDscrChrCnt" class="outputLabel"> <span id="svapdxB6_1:elgRevalIndvQualOthDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxB6_1:elgRevalIndvQualOthDscrChrCnt" type="text" name="svapdxB6_1:elgRevalIndvQualOthDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxB6_1:elgRevalIndvQualOthDscrChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxB6_1:panel_elgRevalIndvQualOthDscr"><textarea id="svapdxB6_1:elgRevalIndvQualOthDscr" name="svapdxB6_1:elgRevalIndvQualOthDscr" class="inputTextarea15" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="noShow"><label><input id="svapdxB6_1:elgRevalIndvQualDscr:2" type="radio" name="svapdxB6_1:elgRevalIndvQualDscr" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </LI> <LI> <div class="outputTextNB"> <strong>Procedures to Ensure Timely Reevaluations.</strong> <label id="svapdxB6_1:lblelgRevalProc" for="svapdxB6_1:elgRevalProc" class="outputLabel"> <span id="svapdxB6_1:lbltxtelgRevalProc1" class="outputTextNB">Per 42 CFR &sect;441.303(c)(4), specify the procedures that the State employs to ensure timely reevaluations of level of care </span><span id="svapdxB6_1:lbltxtelgRevalProc2" class="outputTextNB em"> (specify):</span></label> <p></p> </div> <div class="chrCntDiv"> <label id="svapdxB6_1:elgRevalProcChrCntLbl" for="svapdxB6_1:elgRevalProcChrCnt" class="outputLabel"> <span id="svapdxB6_1:elgRevalProcChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxB6_1:elgRevalProcChrCnt" type="text" name="svapdxB6_1:elgRevalProcChrCnt" class="chrCnt" size="6" /><span id="svapdxB6_1:elgRevalProcChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxB6_1:panel_elgRevalProc"><textarea id="svapdxB6_1:elgRevalProc" name="svapdxB6_1:elgRevalProc" class="inputTextarea15" onkeyup="Count(this);" readonly="readonly">Reevaluations are an administrative component performed by Access Agency care managers. DSS utilizes an electronic case management system in which care plan review dates are logged. The system has a tickler feature that allows it to prompt workers when care plans are due.</textarea></span> </div> </LI> <LI> <div class="outputTextNB"> <strong>Maintenance of Evaluation/Reevaluation Records.</strong> <label id="svapdxB6_1:lblelgEvalRecLoc" for="svapdxB6_1:elgEvalRecLoc" class="outputLabel"> <span id="svapdxB6_1:lbltxtelgEvalRecLoc" class="outputTextNB">Per 42 CFR &sect;441.303(c)(3), the State assures that written and/or electronically retrievable documentation of all evaluations and reevaluations are maintained for a minimum period of 3 years as required in 45 CFR &sect;92.42. Specify the location(s) where records of evaluations and reevaluations of level of care are maintained:</span></label> <p></p> </div> <div class="chrCntDiv"> <label id="svapdxB6_1:elgEvalRecLocChrCntLbl" for="svapdxB6_1:elgEvalRecLocChrCnt" class="outputLabel"> <span id="svapdxB6_1:elgEvalRecLocChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxB6_1:elgEvalRecLocChrCnt" type="text" name="svapdxB6_1:elgEvalRecLocChrCnt" class="chrCnt" size="6" /><span id="svapdxB6_1:elgEvalRecLocChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxB6_1:panel_elgEvalRecLoc"><textarea id="svapdxB6_1:elgEvalRecLoc" name="svapdxB6_1:elgEvalRecLoc" class="inputTextarea15" onkeyup="Count(this);" readonly="readonly">Written copies of the care plan evaluations and reevaluations documents are maintained by the Department of Social Services Alternate Care Unit and access agency records in conformance with 42 CFR 441.303 (c)(3) and 45 CFR 74.53. The DSS case management database also retains an electronic record of the performance of evaluations and reevaluations. As a back-up the fiscal intermediary maintains copies of approved care plans.</textarea></span> </div> </LI> </ol> <H2 id="pageTitle">Appendix B: Evaluation/Reevaluation of Level of Care</H2> <H3 id="pageSubTitle">Quality Improvement: Level of Care</H3> <div class="paragraph"> <span class="outputTextNB em"> As a distinct component of the State’s quality improvement strategy, provide information in the following fields to detail the State’s methods for discovery and remediation. </span> </div> <ol class="alphaLC" id="BQa" start="1" > <li style="margin-top: 1em;"> <div class="paragraph"> <span class="outputText">Methods for Discovery: Level of Care Assurance/Sub-assurances</span> <p class="pph"> <span class="outputText em">The state demonstrates that it implements the processes and instrument(s) specified in its approved waiver for evaluating/reevaluating an applicant's/waiver participant's level of care consistent with level of care provided in a hospital, NF or ICF/IID.</span> </p> </div> <ol class="romanLC" id="BQai" start="1"> <li> <!-- a.i. --> <div>Sub-Assurances:</div> <ol class="alphaLC" start="1"> <li style="padding-bottom: 1em;"> <!-- a.i.a --> <div> <p> <span id="svapdxBQ_1:aiaSA" class="outputText em">Sub-assurance: An evaluation for LOC is provided to all applicants for whom there is reasonable indication that services may be needed in the future.</span> </p> <p class="pph"> <span class="outputText">Performance Measures</span> </p> <p class="pph"> <span id="svapdxBQ_1:aiaPMInfo1" class="outputTextNB em">For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.</span> </p> <p class="pph"> <span id="svapdxBQ_1:aiaPMInstr1" class="outputTextNB em ul">For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.</span> </p> </div> <div class=""> <table id="svapdxBQ_1:dtPMPrnt_loca" class="nstTableX" summary="Expanded dynamic table for services" ><tbody > <tr ><td > <div style="padding-bottom: 1.5em; width:90%;" > <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:pmName" class="inputTextPct">The number and percent of new PCA waiver enrollees whose level of care determination has been reviewed by Department supervisory level staff. Numerator= number of LOC determinations reviewed and denominator= number of new enrollees</span> </div> </div> <table id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource" style="width: 90%" class="nstTableX" border="0" cellpadding="2" cellspacing="0" summary="dynamic table for Performance Measure Data Sources" ><tbody > <tr ><td ><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Record reviews, off-site</span><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct"></span></div></div></div><table id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:pmPnlGrdChkboxSet" class="nstTableX" border="1" cellpadding="3" cellspacing="0" style="vertical-align: top; margin-bottom: 1.5em;"> <tbody> <tr> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsSaPct" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaLtPct" class="outputText">Less than 100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsFdQu" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsFdCo" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsSaOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:0:dssa6"></span></td> </tr> </tbody> </table> </td> </tr> <tr ><td ><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsTypeLbl" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsType"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsTypeDDDiv"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsType" class="inputText">Record reviews, on-site</span><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsOtherNamelblDiv"><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsNameLbl" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsName"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:panel_dsName"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsName" class="inputTextPct"></span></div></div></div><table id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:pmPnlGrdChkboxSet" class="nstTableX" border="1" cellpadding="3" cellspacing="0" style="vertical-align: top; margin-bottom: 1.5em;"> <tbody> <tr> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsrp1"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:PMrp1div" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsRpSma" type="checkbox" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:lbl_dsRpSma" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsRpSma" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsfom1"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsFdWkdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsFdWk" type="checkbox" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:lbl_dsFdWk" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsFdWk" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dssa1"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsSaPctdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsSaPct" type="checkbox" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsSaPct" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:lbl_dsSaPct" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsSaPct" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsrp2"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsRpOpadiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsRpOpa" type="checkbox" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:lbl_dsRpOpa" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsRpOpa" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsfom2"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsFdModiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsFdMo" type="checkbox" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:lbl_dsFdMo" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsFdMo" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dssa2"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsSaLtPct" type="checkbox" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsSaLtPct" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:lbl_dsSaLtPct" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsSaLtPct" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsSaLtPct" class="outputText">Less than 100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsrp3"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsRpCmadiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsRpCma" type="checkbox" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:lbl_dsRpCma" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsRpCma" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsfom3"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsFdQudiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsFdQu" type="checkbox" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:lbl_dsFdQu" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsFdQu" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dssa3" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsSaRsdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsSaRs" type="checkbox" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:lbl_dsSaRs" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsSaRs" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:lbl2_dsSaRsDsc" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsSaRsDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:panel_dsSaRsDsc"><textarea id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsSaRsDsc" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsSaRsDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsrp4"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsRpOthdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsRpOth" type="checkbox" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:lbl_dsRpOth" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsRpOth" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:lbl2_dsRpOthDsc" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsRpOthDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:panel_dsRpOthDsc"><textarea id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsRpOthDsc" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsRpOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsfom4"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsFdAndiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsFdAn" type="checkbox" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:lbl_dsFdAn" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsFdAn" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dssa4" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsSaStrdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsSaStr" type="checkbox" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:lbl_dsSaStr" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsSaStr" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:lbl2_dsSaStrDsc" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsSaStrDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:panel_dsSaStrDsc"><textarea id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsSaStrDsc" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsSaStrDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsrp5"></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsfom5"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsFdCodiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsFdCo" type="checkbox" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsFdCo" checked="checked" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:lbl_dsFdCo" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsFdCo" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dssa5" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsSaOthdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsSaOth" type="checkbox" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsSaOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:lbl_dsSaOth" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsSaOth" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:lbl2_dsSaOthDsc" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsSaOthDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:panel_dsSaOthDsc"><textarea id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsSaOthDsc" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsSaOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsrp6"></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsfom6"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsFdOtdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsFdOt" type="checkbox" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:lbl_dsFdOt" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsFdOt" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:lbl2_dsFdOtDsc" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsFdOtDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:panel_dsFdOtDsc"><textarea id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsFdOtDsc" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:dtDataSource:1:dssa6"></span></td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <div style="padding: 1em 0 1em 0;"> </div> <div> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:pmDAA" class="outputText" style="margin-top: 1.5em;">Data Aggregation and Analysis:</span> </div> <table id="pmPnlGrdChkboxSet" class="nstTableX" id="pmPnlGrdChkboxSet"cellpadding="3" cellspacing="0" border="1" style="vertical-align: top; width: 85%;"> <THEAD><tr align="left" valign="top"> <th id="rp" class="third"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:txtPMfom2" class="outputTextNB em">(check each that applies):</span> </th> </tr></THEAD> <TBODY valign="top" align="left"> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:pmDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:pmDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:pmDaFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:pmDaRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:pmDaRpOthDsc" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:pmDaRpOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:pmDaFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:txtlbl_pmDaFdAn" class="outputText">Annually</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:pmDaFdCo" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:txtlblpmDaFdCo" class="outputText">Continuously and Ongoing</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup" > <input id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:pmDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:pmDaFdOtDsc" name="svapdxBQ_1:dtPMPrnt_loca:0:svQmPerfMeas:pmDaFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> </tr> </TBODY> </table> <div> </div> </td> </tr> </tbody> </table> </div> </li> <li style="padding-bottom: 1em;"> <!-- a.i.b --> <div> <p> <span id="svapdxBQ_1:aibSA" class="outputText em">Sub-assurance: The levels of care of enrolled participants are reevaluated at least annually or as specified in the approved waiver.</span> </p> <p class="pph"> <span class="outputText">Performance Measures</span> </p> <p class="pph"> <span id="svapdxBQ_1:aibPMInfo1" class="outputTextNB em">For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.</span> </p> <p class="pph"> <span id="svapdxBQ_1:aibPMInstr1" class="outputTextNB em ul">For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.</span> </p> </div> <div class=""> <table id="svapdxBQ_1:dtPMPrnt_locb" class="nstTableX" summary="Expanded dynamic table for services" ><tbody > <tr ><td > <div style="padding-bottom: 1.5em; width:90%;" > <span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:pmName" class="inputTextPct">The number and percent of annual reassessments completely timely. The numerator is the number of reassessments done timely and the denominator is the total number of reassessments due.</span> </div> </div> <table id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource" style="width: 90%" class="nstTableX" border="0" cellpadding="2" cellspacing="0" summary="dynamic table for Performance Measure Data Sources" ><tbody > <tr ><td ><label id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Other</span><div id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct">Ad hoc reports</span></div></div></div><table id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:pmPnlGrdChkboxSet" class="nstTableX" border="1" cellpadding="3" cellspacing="0" style="vertical-align: top; margin-bottom: 1.5em;"> <tbody> <tr> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsSaPct" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaLtPct" class="outputText">Less than 100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsFdQu" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsFdCo" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsSaOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsFdOt" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="inputTextarea" readonly="readonly">As needed</textarea></span></div></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:dtDataSource:0:dssa6"></span></td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <div style="padding: 1em 0 1em 0;"> </div> <div> <span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:pmDAA" class="outputText" style="margin-top: 1.5em;">Data Aggregation and Analysis:</span> </div> <table id="pmPnlGrdChkboxSet" class="nstTableX" id="pmPnlGrdChkboxSet"cellpadding="3" cellspacing="0" border="1" style="vertical-align: top; width: 85%;"> <THEAD><tr align="left" valign="top"> <th id="rp" class="third"> <span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:txtPMfom2" class="outputTextNB em">(check each that applies):</span> </th> </tr></THEAD> <TBODY valign="top" align="left"> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:pmDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:pmDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:pmDaFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:pmDaRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:pmDaRpOthDsc" name="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:pmDaRpOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:pmDaFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:txtlbl_pmDaFdAn" class="outputText">Annually</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:pmDaFdCo" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:txtlblpmDaFdCo" class="outputText">Continuously and Ongoing</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup" > <input id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:pmDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:pmDaFdOtDsc" name="svapdxBQ_1:dtPMPrnt_locb:0:svQmPerfMeas:pmDaFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> </tr> </TBODY> </table> <div> </div> </td> </tr> </tbody> </table> </div> </li> <li style="padding-bottom: 1em;"> <!-- a.i.c --> <div> <p> <span id="svapdxBQ_1:aicSA" class="outputText em">Sub-assurance: The processes and instruments described in the approved waiver are applied appropriately and according to the approved description to determine participant level of care.</span> </p> <p class="pph"> <span class="outputText">Performance Measures</span> </p> <p class="pph"> <span id="svapdxBQ_1:aicPMInfo1" class="outputTextNB em">For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.</span> </p> <p class="pph"> <span id="svapdxBQ_1:aicPMInstr1" class="outputTextNB em ul">For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.</span> </p> </div> <div class=""> <table id="svapdxBQ_1:dtPMPrnt_locc" class="nstTableX" summary="Expanded dynamic table for services" ><tbody > <tr ><td > <div style="padding-bottom: 1.5em; width:90%;" > <span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:pmName" class="inputTextPct">Number and percent of records that have a completed level of care determination form. The numerator is the number of records that have a completed LOC determination form and the denominator is the total number of records.</span> </div> </div> <table id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource" style="width: 90%" class="nstTableX" border="0" cellpadding="2" cellspacing="0" summary="dynamic table for Performance Measure Data Sources" ><tbody > <tr ><td ><label id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Record reviews, on-site</span><div id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct"></span></div></div></div><table id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:pmPnlGrdChkboxSet" class="nstTableX" border="1" cellpadding="3" cellspacing="0" style="vertical-align: top; margin-bottom: 1.5em;"> <tbody> <tr> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsSaPct" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaLtPct" class="outputText">Less than 100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsFdCo" checked="checked" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsSaOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:dtDataSource:0:dssa6"></span></td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <div style="padding: 1em 0 1em 0;"> </div> <div> <span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:pmDAA" class="outputText" style="margin-top: 1.5em;">Data Aggregation and Analysis:</span> </div> <table id="pmPnlGrdChkboxSet" class="nstTableX" id="pmPnlGrdChkboxSet"cellpadding="3" cellspacing="0" border="1" style="vertical-align: top; width: 85%;"> <THEAD><tr align="left" valign="top"> <th id="rp" class="third"> <span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:txtPMfom2" class="outputTextNB em">(check each that applies):</span> </th> </tr></THEAD> <TBODY valign="top" align="left"> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:pmDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:pmDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:pmDaFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:pmDaRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:pmDaRpOthDsc" name="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:pmDaRpOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:pmDaFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:txtlbl_pmDaFdAn" class="outputText">Annually</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:pmDaFdCo" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:txtlblpmDaFdCo" class="outputText">Continuously and Ongoing</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup" > <input id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:pmDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:pmDaFdOtDsc" name="svapdxBQ_1:dtPMPrnt_locc:0:svQmPerfMeas:pmDaFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> </tr> </TBODY> </table> <div> </div> </td> </tr> </tbody> </table> </div> </li> </ol> </li> <li style="padding-top: 1.5em;"> <!-- a.ii. --> <div class="paragraph"> <label id="svapdxBQ_1:lbl_qmLocDiscDesc" for="svapdxBQ_1:qmLocDiscDesc" class="outputLabel"> <span id="svapdxBQ_1:txt_lbl_qmLocDiscDesc" class="outputTextNB">If applicable, in the textbox below provide any necessary additional information on the strategies employed by the State to discover/identify problems/issues within the waiver program, including frequency and parties responsible.</span></label> </div> <div></div> <div class="chrCntDiv"> <label id="svapdxBQ_1:qmLocDiscDescChrCntLbl" for="svapdxBQ_1:qmLocDiscDescChrCnt" class="outputLabel"> <span id="svapdxBQ_1:qmLocDiscDescChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxBQ_1:qmLocDiscDescChrCnt" type="text" name="svapdxBQ_1:qmLocDiscDescChrCnt" class="chrCnt" size="6" /><span id="svapdxBQ_1:qmLocDiscDescChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxBQ_1:panel_qmLocDiscDesc"><textarea id="svapdxBQ_1:qmLocDiscDesc" name="svapdxBQ_1:qmLocDiscDesc" class="inputTextarea" onkeyup="Count(this);" readonly="readonly">If a consumer'’s level of care is thought to be inappropriate during any part of the evaluation process, the individual is reassessed by the care manager with oversight by the department's PCA Waiver manager to insure that all necessary factors have been considered in assigning the care level.</textarea></span> </div> </li> </ol> </li> <li style="margin-top: 1em;"> <!-- b. --> <div class="paragraph"> <span class="outputText">Methods for Remediation/Fixing Individual Problems</span> </div> <ol class="romanLC" id="AQb" start="1"> <li> <!-- b.i. --> <div class="paragraph"> <label id="svapdxBQ_1:lbl_qmLocRemDesc" for="svapdxBQ_1:qmLocRemDesc" class="outputLabel"> <span id="svapdxBQ_1:txt_lbl_qmLocRemDesc" class="outputTextNB">Describe the State’s method for addressing individual problems as they are discovered. Include information regarding responsible parties and GENERAL methods for problem correction. In addition, provide information on the methods used by the State to document these items. </span></label> </div> <div></div> <div class="chrCntDiv"> <label id="svapdxBQ_1:qmLocRemDescChrCntLbl" for="svapdxBQ_1:qmLocRemDescChrCnt" class="outputLabel"> <span id="svapdxBQ_1:qmLocRemDescChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxBQ_1:qmLocRemDescChrCnt" type="text" name="svapdxBQ_1:qmLocRemDescChrCnt" class="chrCnt" size="6" /><span id="svapdxBQ_1:qmLocRemDescChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxBQ_1:panel_qmLocRemDesc"><textarea id="svapdxBQ_1:qmLocRemDesc" name="svapdxBQ_1:qmLocRemDesc" class="inputTextarea" onkeyup="Count(this);" readonly="readonly">The care manager will re-assess a client if it appears that they require a different level of care. If it is determined that a level of care is either too high or too low, the service plan is adjusted and a Notice of Action is sent to the client. The consumer is afforded full access to the Medicaid appeals process, which is administered by the DSS Office of Legal Counsel, Regulations, and Fair Hearings.</textarea></span> </div> </li> <li> <!-- b.ii. --> <div class="paragraph"> <span id="svapdxBQ_1:txt1">Remediation Data Aggregation</span> </div> <div> <span id="svapdxBQ_1:txt2">Remediation-related Data Aggregation and Analysis (including trend identification)</span> <table cellpadding="3" cellspacing="0" border="1" class="nstTableX" style="width:88%"> <thead align="left"> <tr> <th id="rp" style="width:44%;"> <span id="svapdxBQ_1:txtrp">Responsible Party</span><span id="svapdxBQ_1:txtrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" style="width:44%;"> <span id="svapdxBQ_1:txtfom">Frequency of data aggregation and analysis</span><span id="svapdxBQ_1:txtfom2" class="outputTextNB em">(check each that applies):</span> </th> </tr> </thead> <tbody align="left" valign="top"> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxBQ_1:qmLocDaRpSma" type="checkbox" name="svapdxBQ_1:qmLocDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:lbl_qmLocDaRpSma" for="svapdxBQ_1:qmLocDaRpSma" class="outputLabel"> <span id="svapdxBQ_1:txtlbl_qmLocDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxBQ_1:qmLocDaFdWk" type="checkbox" name="svapdxBQ_1:qmLocDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:lbl_qmLocDaFdWk" for="svapdxBQ_1:qmLocDaFdWk" class="outputLabel"> <span id="svapdxBQ_1:txtlbl_qmLocDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxBQ_1:qmLocDaRpOpa" type="checkbox" name="svapdxBQ_1:qmLocDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:lbl_qmLocDaRpOpa" for="svapdxBQ_1:qmLocDaRpOpa" class="outputLabel"> <span id="svapdxBQ_1:txtlbl_qmLocDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxBQ_1:qmLocDaFdMo" type="checkbox" name="svapdxBQ_1:qmLocDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:lbl_qmLocDaFdMo" for="svapdxBQ_1:qmLocDaFdMo" class="outputLabel"> <span id="svapdxBQ_1:txtlbl_qmLocDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxBQ_1:qmLocDaRpCma" type="checkbox" name="svapdxBQ_1:qmLocDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:lbl_qmLocDaRpCma" for="svapdxBQ_1:qmLocDaRpCma" class="outputLabel"> <span id="svapdxBQ_1:txtlbl_qmLocDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxBQ_1:qmLocDaFdQu" type="checkbox" name="svapdxBQ_1:qmLocDaFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:lbl_qmLocDaFdQu" for="svapdxBQ_1:qmLocDaFdQu" class="outputLabel"> <span id="svapdxBQ_1:txtlbl_qmLocDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxBQ_1:qmLocDaRpOth" type="checkbox" name="svapdxBQ_1:qmLocDaRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:lbl_qmLocDaRpOth" for="svapdxBQ_1:qmLocDaRpOth" class="outputLabel"> <span id="svapdxBQ_1:txtlbl_qmLocDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxBQ_1:lbl2_qmLocDaRpOthDsc" for="svapdxBQ_1:qmLocDaRpOthDsc" class="outputLabel"> <span id="svapdxBQ_1:txtlbl2_qmLocDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxBQ_1:panel_qmLocDaRpOthDsc"><textarea id="svapdxBQ_1:qmLocDaRpOthDsc" name="svapdxBQ_1:qmLocDaRpOthDsc" class="inputTextarea" readonly="readonly"></textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxBQ_1:qmLocDaFdAn" type="checkbox" name="svapdxBQ_1:qmLocDaFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:lbl_qmLocDaFdAn" for="svapdxBQ_1:qmLocDaFdAn" class="outputLabel"> <span id="svapdxBQ_1:txtlbl_qmLocDaFdAn" class="outputText">Annually</span></label> </div> </td> </tr> <tr> <td headers="rp"> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxBQ_1:qmLocDaFdCo" type="checkbox" name="svapdxBQ_1:qmLocDaFdCo" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxBQ_1:lbl_qmLocDaFdCo" for="svapdxBQ_1:qmLocDaFdCo" class="outputLabel"> <span id="svapdxBQ_1:txtlblqmLocDaFdCo" class="outputText">Continuously and Ongoing</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxBQ_1:qmLocDaFdOt" type="checkbox" name="svapdxBQ_1:qmLocDaFdOt" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxBQ_1:lbl_qmLocDaFdOt" for="svapdxBQ_1:qmLocDaFdOt" class="outputLabel"> <span id="svapdxBQ_1:txtlblqmLocDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxBQ_1:lbl2_qmLocDaFdOtDsc" for="svapdxBQ_1:qmLocDaFdOtDsc" class="outputLabel"> <span id="svapdxBQ_1:txtlbl2qmLocDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxBQ_1:panel_qmLocDaFdOtDsc"><textarea id="svapdxBQ_1:qmLocDaFdOtDsc" name="svapdxBQ_1:qmLocDaFdOtDsc" class="inputTextarea" readonly="readonly">as needed</textarea></span> </div> </div> </td> </tr> </tbody> </table> </div> </li> </ol> </li> <li style="margin-top: 1em;"> <!-- c. --> <div> <span class="outputText">Timelines</span> </div> <div> <label id="svapdxBQ_1:lbl_qmLocTimeLn" for="svapdxBQ_1:qmLocTimeLn" class="outputLabel"> <span id="svapdxBQ_1:txt_lbl_qmLocTimeLn" class="outputTextNB">When the State does not have all elements of the Quality Improvement Strategy in place, provide timelines to design methods for discovery and remediation related to the assurance of Level of Care that are currently non-operational.</span></label> <div> <div class="checkboxGroup"><label><input id="svapdxBQ_1:qmLocTimeLn:1" type="radio" name="svapdxBQ_1:qmLocTimeLn" checked="checked" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;No</label></div> <div class="checkboxGroup"><label><input id="svapdxBQ_1:qmLocTimeLn:0" type="radio" name="svapdxBQ_1:qmLocTimeLn" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;Yes</label></div> <div class="noShow"><label><input id="svapdxBQ_1:qmLocTimeLn:2" type="radio" name="svapdxBQ_1:qmLocTimeLn" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </div> </div> <div class="firstIndent"> <label id="svapdxBQ_1:lbl_qmLocTimeLnDsc" for="svapdxBQ_1:qmLocTimeLnDsc" class="outputLabel"> <span id="svapdxBQ_1:txt_lbl_qmLocTimeLnDsc" class="outputTextNB">Please provide a detailed strategy for assuring Level of Care, the specific timeline for implementing identified strategies, and the parties responsible for its operation.</span></label> <div></div> <div class="chrCntDiv"> <label id="svapdxBQ_1:qmLocTimeLnDscChrCntLbl" for="svapdxBQ_1:qmLocTimeLnDscChrCnt" class="outputLabel"> <span id="svapdxBQ_1:qmLocTimeLnDscChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxBQ_1:qmLocTimeLnDscChrCnt" type="text" name="svapdxBQ_1:qmLocTimeLnDscChrCnt" class="chrCnt" size="6" /><span id="svapdxBQ_1:qmLocTimeLnDscChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxBQ_1:panel_qualc"><textarea id="svapdxBQ_1:qmLocTimeLnDsc" name="svapdxBQ_1:qmLocTimeLnDsc" class="inputTextarea" readonly="readonly"></textarea></span> </div> </div> </li> </ol> <H2 id="pageTitle">Appendix B: Participant Access and Eligibility</H2> <H3 id="pageSubTitle">B-7: Freedom of Choice</H3> <div class="outputTextNB em"> <strong>Freedom of Choice.</strong> As provided in 42 CFR §441.302(d), when an individual is determined to be likely to require a level of care for this waiver, the individual or his or her legal representative is: <ol type="i"> <li>informed of any feasible alternatives under the waiver; and</li> <li>given the choice of either institutional or home and community-based services.</li> </ol> </div> <ol class="alphaLC" start="1"> <li> <div class="outputTextNB"> <strong>Procedures.</strong> <label id="svapdxB7_1:lblelgFOCProc" for="svapdxB7_1:elgFOCProc" class="outputLabel"> <span id="svapdxB7_1:lbltxtelgFOCProc" class="outputTextNB">Specify the State's procedures for informing eligible individuals (or their legal representatives) of the feasible alternatives available under the waiver and allowing these individuals to choose either institutional or waiver services. Identify the form(s) that are employed to document freedom of choice. The form or forms are available to CMS upon request through the Medicaid agency or the operating agency (if applicable).</span></label> </div> <p></p> <div class="chrCntDiv"> <label id="svapdxB7_1:elgFOCProcChrCntLbl" for="svapdxB7_1:elgFOCProcChrCnt" class="outputLabel"> <span id="svapdxB7_1:elgFOCProchrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxB7_1:elgFOCProcChrCnt" type="text" name="svapdxB7_1:elgFOCProcChrCnt" class="chrCnt" size="6" /><span id="svapdxB7_1:elgFOCProcChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxB7_1:panel_elgFOCProc"><textarea id="svapdxB7_1:elgFOCProc" name="svapdxB7_1:elgFOCProc" class="inputTextarea15" onkeyup="Count(this);" readonly="readonly">At the time of screening for eligibility to participate in this waiver, the care manager informs the potential participant of his or her option of receiving services in a long-term care institution or through this waiver. The applicant is informed of any feasible alternatives under the waiver. The individual is also advised of his/her right to a Fair Hearing. This is documented on the (form W-1035) &Acirc; “Freedom of Choice/Fair Hearing Notification”. This form is maintained in the participant'’s case file.</textarea></span> </div> </li> <li> <div class="outputTextNB"> <strong>Maintenance of Forms.</strong> <label id="svapdxB7_1:lblelgFOCFormLoc" for="svapdxB7_1:elgFOCFormLoc" class="outputLabel"> <span id="svapdxB7_1:lbltxtelgFOCFormLoc" class="outputTextNB">Per 45 CFR &sect;92.42, written copies or electronically retrievable facsimiles of Freedom of Choice forms are maintained for a minimum of three years. Specify the locations where copies of these forms are maintained.</span></label> </div> <p></p> <div class="chrCntDiv"> <label id="svapdxB7_1:elgFOCFormLocChrCntLbl" for="svapdxB7_1:elgFOCFormLocChrCnt" class="outputLabel"> <span id="svapdxB7_1:elgFOCFormLocCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxB7_1:elgFOCFormLocChrCnt" type="text" name="svapdxB7_1:elgFOCFormLocChrCnt" class="chrCnt" size="6" /><span id="svapdxB7_1:elgFOCFormLocChrCntMax" class="chrCnt"> out of 4000</span> </div> <div class="inputTextareaWA"> <span id="svapdxB7_1:panel_elgFOCFormLoc"><textarea id="svapdxB7_1:elgFOCFormLoc" name="svapdxB7_1:elgFOCFormLoc" class="inputTextarea" onkeyup="Count(this);" readonly="readonly">All materials pertaining to a specific waiver participant are maintained in their individual file. The signed “Freedom of Choice/Hearing notification” form and other documents are maintained by the Social Worker in the participant'’s case file.</textarea></span> </div> </li> </ol> <H2 id="pageTitle">Appendix B: Participant Access and Eligibility</H2> <H3 id="pageSubTitle">B-8: Access to Services by Limited English Proficiency Persons</H3> <div class="outputTextNB"> <strong>Access to Services by Limited English Proficient Persons.</strong> <label id="svapdxB8_1:lblelgLimEnglAccMth" for="svapdxB8_1:elgLimEnglAccMth" class="outputLabel"> <span id="svapdxB8_1:lbltxtelgLimEnglAccMth1" class="outputTextNB">Specify the methods that the State uses to provide meaningful access to the waiver by Limited English Proficient persons in accordance with the Department of Health and Human Services </span><span id="svapdxB8_1:lbltxtelgLimEnglAccMth2" class="outputTextNB">"Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons"</span><span id="svapdxB8_1:lbltxtelgLimEnglAccMth3" class="outputTextNB"> (68 FR 47311 - August 8, 2003):</span></label> </div> <div></div> <div class="chrCntDiv"> <label id="svapdxB8_1:elgLimEnglAccMthChrCntLbl" for="svapdxB8_1:elgLimEnglAccMthChrCnt" class="outputLabel"> <span id="svapdxB8_1:elgLimEnglAccMthChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxB8_1:elgLimEnglAccMthChrCnt" type="text" name="svapdxB8_1:elgLimEnglAccMthChrCnt" class="chrCnt" size="6" /><span id="svapdxB8_1:elgLimEnglAccMthChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxB8_1:panel_elgLimEnglAccMth"><textarea id="svapdxB8_1:elgLimEnglAccMth" name="svapdxB8_1:elgLimEnglAccMth" class="inputTextareaLong" onkeyup="Count(this);" readonly="readonly">Potential and active waiver participants with limited fluency in English must have access to services without undue hardship. The DSS Request for Waiver Services (W-1130) is available in Spanish. For applicants who speak other languages, the department would utilize our contracted language line to complete the application. DSS social workers are required to make arrangements to provide interpretation or translation services for potential and active waiver participants who need them. This is accomplished through the use of bi-lingual staff and/or purchasing/contracting for interpreters. Non-English speaking waiver applicants/participants may bring an interpreter of their choice with them to the DSS planning meetings. They cannot, however, be required to bring their own interpreter. No person can be denied access on the basis of English proficiency.</textarea></span> </div> <H2 id="pageTitle">Appendix C: Participant Services</H2> <H3 id="pageSubTitle">C-1: Summary of Services Covered <SPAN id="pageNumber">(1 of 2)</SPAN></H3> <OL class="alphaLC" start="1"> <LI> <div class="outputTextNB"> <strong>Waiver Services Summary. </strong> <em>List the services that are furnished under the waiver in the following table. If case management is not a service under the waiver, complete items C-1-b and C-1-c:</em> </div> <table id="svapdxC1_1:dtServices" class="dtServices width98" border="1" cellpadding="2" cellspacing="0" summary="dynamic table for services" ><thead ><tr ><th scope="col" ><span id="svapdxC1_1:dtServices:colServiceType" class="outputText" style="width: 40%;">Service Type</span></th><th scope="col" ><span id="svapdxC1_1:dtServices:colServiceName" class="outputText" style="width: 60%;">Service</span></th><th scope="col" ><img src="/WMS/.ibmjsfres/img/1x1.gif" ></img></th><th scope="col" ><img src="/WMS/.ibmjsfres/img/1x1.gif" ></img></th></tr> </thead><tbody > <tr ><td ><input id="svapdxC1_1:dtServices:0:serviceID" type="text" name="svapdxC1_1:dtServices:0:serviceID" value="220784" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1:dtServices:0:serviceType" class="outputText">Statutory Service</span></td> <td ><span id="svapdxC1_1:dtServices:0:serviceName" class="outputText">Care Management</span></td> <td ></td> <td ></td> </tr> <tr ><td ><input id="svapdxC1_1:dtServices:1:serviceID" type="text" name="svapdxC1_1:dtServices:1:serviceID" value="212286" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1:dtServices:1:serviceType" class="outputText">Supports for Participant Direction</span></td> <td ><span id="svapdxC1_1:dtServices:1:serviceName" class="outputText">Independent Support Broker</span></td> <td ></td> <td ></td> </tr> <tr ><td ><input id="svapdxC1_1:dtServices:2:serviceID" type="text" name="svapdxC1_1:dtServices:2:serviceID" value="200881" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1:dtServices:2:serviceType" class="outputText">Other Service</span></td> <td ><span id="svapdxC1_1:dtServices:2:serviceName" class="outputText">Adult Family Living/Foster Care</span></td> <td ></td> <td ></td> </tr> </tbody> </table> <div class="pph"> </div> </LI> </OL> <div class="firstIndent"> <table id="svapdxC1_1_prnt:dtServicesPrnt" class="nstTableX" summary="Expanded dynamic table for services" ><tbody > <tr ><td > <LINK rel="stylesheet" type="text/css" href="/WMS/theme/twoColTable.css" media="print,screen"> <H2 id="pageTitle">Appendix C: Participant Services</H2> <H3 id="pageSubTitle">C-1/C-3: Service Specification</H3> <table width="100%" style="margin: 10px 0;" id="TblSvcNavTop"> <tr> <td width="50%" align="left"> </td> <td width="50%" align="right"> </td> </tr> </table> <div class="pph"> <span class="outputTextNB"> State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable). </span> </div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:lbl_svcType" for="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcType" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:txt_lbl_svcType" class="outputText">Service Type:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcType" name="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcType" size="1" onchange="return callSave(this, event);" disabled="disabled"> <option value="0" selected="selected">Statutory Service</option> <option value="1">Extended State Plan Service</option> <option value="2">Supports for Participant Direction</option> <option value="3">Other Service</option> </select> <div> <div class="outputText"> <label id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:lbl_STsvcName" for="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:STsvcName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:txt_lbl_STsvcName" class="outputText">Service:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:STsvcName" name="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:STsvcName" size="1" disabled="disabled"> <option value="00" selected="selected">Case Management</option> <option value="02">Homemaker</option> <option value="03">Home Health Aide</option> <option value="04">Personal Care</option> <option value="05">Adult Day Health</option> <option value="06">Habilitation</option> <option value="07">Residential Habilitation</option> <option value="08">Day Habilitation</option> <option value="09">Prevocational Services</option> <option value="10">Supported Employment</option> <option value="11">Education</option> <option value="12">Respite</option> <option value="13">Day Treatment</option> <option value="14">Partial Hospitalization</option> <option value="15">Psychosocial Rehabilitation</option> <option value="16">Clinic Services</option> <option value="17">Live-in Caregiver (42 CFR &sect;441.303(f)(8))</option> </select> </div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:label1" for="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcAltName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:lblAlternateServiceTitle" class="outputText">Alternate Service Title (if any):</span></label> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:panel_svcAltName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcAltName" name="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcAltName" class="inputTextarea" readonly="readonly">Care Management</textarea></span> </div> </div> <div Class="pph"> <p class="outputText">HCBS Taxonomy:</p> <div class="firstIndent"> <div id="tblSummaryInfo" style="clear:both;"> <div class="rowContact"> <div class="leftCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:lbl_svcTaxCat1" for="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcTaxCat1" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:txt_lbl_svcTaxCat1" class="outputText">Category 1:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcTaxCat1" name="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcTaxCat1" class="selectOneMenuLong" size="1" onchange="document.getElementById('template:svapdxC1_1a:svcTaxSubCat1').value='99';return callSave(this, event);" disabled="disabled"> <option value="01">01 Case Management</option> <option value="02">02 Round-the-Clock Services</option> <option value="03">03 Supported Employment</option> <option value="04">04 Day Services</option> <option value="05">05 Nursing</option> <option value="06">06 Home Delivered Meals</option> <option value="07">07 Rent and Food Expenses for Live-In Caregiver</option> <option value="08">08 Home-Based Services</option> <option value="09">09 Caregiver Support</option> <option value="10">10 Other Mental Health and Behavioral Services</option> <option value="11">11 Other Health and Therapeutic Services</option> <option value="12">12 Services Supporting Self-Direction</option> <option value="13">13 Participant Training</option> <option value="14">14 Equipment, Technology, and Modifications</option> <option value="15">15 Non-Medical Transportation</option> <option value="16">16 Community Transition Services</option> <option value="17">17 Other Services</option> <option value="99" selected="selected"> </option> </select> </div> <div class="rightCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:lbl_svcTaxSubCat1" for="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcTaxSubCat1" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:txt_lbl_svcTaxSubCat1" class="outputText">Sub-Category 1:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcTaxSubCat1" name="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcTaxSubCat1" class="selectOneMenuLong" size="1" disabled="disabled"> <option value="99" selected="selected"> </option> </select> </div> </div> <div class="rowContact"> <div class="leftCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:lbl_taxCat2" for="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcTaxCat2" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:txt_lbl_taxCat2" class="outputText">Category 2:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcTaxCat2" name="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcTaxCat2" class="selectOneMenuLong" size="1" onchange="document.getElementById('template:svapdxC1_1a:svcTaxSubCat2').value='99';return callSave(this, event);" disabled="disabled"> <option value="01">01 Case Management</option> <option value="02">02 Round-the-Clock Services</option> <option value="03">03 Supported Employment</option> <option value="04">04 Day Services</option> <option value="05">05 Nursing</option> <option value="06">06 Home Delivered Meals</option> <option value="07">07 Rent and Food Expenses for Live-In Caregiver</option> <option value="08">08 Home-Based Services</option> <option value="09">09 Caregiver Support</option> <option value="10">10 Other Mental Health and Behavioral Services</option> <option value="11">11 Other Health and Therapeutic Services</option> <option value="12">12 Services Supporting Self-Direction</option> <option value="13">13 Participant Training</option> <option value="14">14 Equipment, Technology, and Modifications</option> <option value="15">15 Non-Medical Transportation</option> <option value="16">16 Community Transition Services</option> <option value="17">17 Other Services</option> <option value="99" selected="selected"> </option> </select> </div> <div class="rightCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:lbl_taxSubCat2" for="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcTaxSubCat2" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:txt_lbl_taxSubCat2" class="outputText">Sub-Category 2:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcTaxSubCat2" name="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcTaxSubCat2" class="selectOneMenuLong" size="1" disabled="disabled"> <option value="99" selected="selected"> </option> </select> </div> </div> <div class="rowContact"> <div class="leftCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:lbl_taxCat3" for="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcTaxCat3" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:txt_lbl_taxCat3" class="outputText">Category 3:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcTaxCat3" name="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcTaxCat3" class="selectOneMenuLong" size="1" onchange="document.getElementById('template:svapdxC1_1a:svcTaxSubCat3').value='99';return callSave(this, event);" disabled="disabled"> <option value="01">01 Case Management</option> <option value="02">02 Round-the-Clock Services</option> <option value="03">03 Supported Employment</option> <option value="04">04 Day Services</option> <option value="05">05 Nursing</option> <option value="06">06 Home Delivered Meals</option> <option value="07">07 Rent and Food Expenses for Live-In Caregiver</option> <option value="08">08 Home-Based Services</option> <option value="09">09 Caregiver Support</option> <option value="10">10 Other Mental Health and Behavioral Services</option> <option value="11">11 Other Health and Therapeutic Services</option> <option value="12">12 Services Supporting Self-Direction</option> <option value="13">13 Participant Training</option> <option value="14">14 Equipment, Technology, and Modifications</option> <option value="15">15 Non-Medical Transportation</option> <option value="16">16 Community Transition Services</option> <option value="17">17 Other Services</option> <option value="99" selected="selected"> </option> </select> </div> <div class="rightCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:lbl_taxSubCat3" for="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcTaxSubCat3" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:txt_lbl_taxSubCat3" class="outputText">Sub-Category 3:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcTaxSubCat3" name="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcTaxSubCat3" class="selectOneMenuLong" size="1" disabled="disabled"> <option value="99" selected="selected"> </option> </select> </div> </div> <div class="rowContact"> <div class="leftCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:lbl_taxCat4" for="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcTaxCat4" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:txt_lbl_taxCat4" class="outputText">Category 4:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcTaxCat4" name="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcTaxCat4" class="selectOneMenuLong" size="1" onchange="document.getElementById('template:svapdxC1_1a:svcTaxSubCat4').value='99';return callSave(this, event);" disabled="disabled"> <option value="01">01 Case Management</option> <option value="02">02 Round-the-Clock Services</option> <option value="03">03 Supported Employment</option> <option value="04">04 Day Services</option> <option value="05">05 Nursing</option> <option value="06">06 Home Delivered Meals</option> <option value="07">07 Rent and Food Expenses for Live-In Caregiver</option> <option value="08">08 Home-Based Services</option> <option value="09">09 Caregiver Support</option> <option value="10">10 Other Mental Health and Behavioral Services</option> <option value="11">11 Other Health and Therapeutic Services</option> <option value="12">12 Services Supporting Self-Direction</option> <option value="13">13 Participant Training</option> <option value="14">14 Equipment, Technology, and Modifications</option> <option value="15">15 Non-Medical Transportation</option> <option value="16">16 Community Transition Services</option> <option value="17">17 Other Services</option> <option value="99" selected="selected"> </option> </select> </div> <div class="rightCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:lbl_taxSubCat4" for="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcTaxSubCat4" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:txt_lbl_taxSubCat4" class="outputText">Sub-Category 4:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcTaxSubCat4" name="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcTaxSubCat4" class="selectOneMenuLong" size="1" disabled="disabled"> <option value="99" selected="selected"> </option> </select> </div> </div> </div> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:lbl_svcDef" for="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcDef" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:lbl_txt_svcDef1" class="outputText">Service Definition</span><span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:lbl_txt_svcDef2" class="outputTextNB em"> (Scope):</span></label> </div> <div></div> <div Class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:panel_svcDef"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcDef" name="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcDef" class="inputTextarea" readonly="readonly">Services that assist participants in gaining access to needed waiver and other State plan services, as well as medical, social, educational and other services, regardless of the funding source for the services to which access is gained. Care managers additionally are responsible to monitor the ongoing provision of services in the participant's plan of care and continually monitor that the client's health annd safety needs are being addressed. They complete the initial and annual assessment and reassessment of an individual's needs in order to develop a comprehensive plan of care. They confirm the initial level of care determination done by Department staff and reassess the level of care annually and maintain documentation for Department review. Care Managers also explain opportunites for participant directed services options to participants. For clients who are able to direct their own services, Department nurses and social workers perform the annual reassessments and level of care determinations. DSS will be implementing a tiered case management system. Tiered case management is based on client's level of need and the number and type of case management interventions required. TIER A clients, with the fewest needs, receive a quarterly contact and an annual reassessment. Leveling Criteria for TIER A is 3 or less care management interventions in a 6 month period. If 2 of those interventions are crisis interventions, client is automatically elevated to level 2. TIER B clients receive monthly monitoring, a six month field visit and an annual reassessment. Leveling criteria is 4-6 care management interventions in a 6 month period. TIER C clients, the highest level, receive monthly monitoring, quarterly field visits, six month visit, and an annual reassessment. Leveling criteria is 7 or more care management interventions in a 6 month period. There are four categories of case management intervention: Crisis Intervention, Service Brokerage and Advocacy, Risk Management and Client Engagement/Re-engagement. Care management interventions are weighted according to complexity, severity and number of tasks required. Crisis intervention is weighted highest followed by Service Brokerage and Advocacy, Risk Management and Client Engagement/Re-engagement. Clients may move to a different tier based on their current needs with prior authorization from DSS. Care management per diem rates will be adjusted according to which tier the client is in. the rate methodology is described in Appendix I-2. Providers are selected as a result of a competitive bidding process and approved, qualified providers are directly enrolled as Medicaid providers. Client choice is assured as they can request a change in their care manager at any time.</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:lbl_svcLimDscr" for="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcLimDscr" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:txt_lbl_svcLimDscr" class="outputText">Specify applicable (if any) limits on the amount, frequency, or duration of this service:</span></label> </div> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:panel_svcLimDscr"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcLimDscr" name="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcLimDscr" class="inputTextarea" readonly="readonly">Service may be billed on a per diem basis as long as the client remains in a community-based setting.</textarea></span> </div> </div> <div Class="pph"> <p class="outputTextNB"><strong>Service Delivery Method </strong> <em>(check each that applies)</em>: </p> <div class="firstIndent"> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcDelMthPtcDir" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcDelMthPtcDir" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:lbl_svcDelMthPtcDir" for="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcDelMthPtcDir" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:txt_lbl_svcDelMthPtcDir" class="outputText">Participant-directed as specified in Appendix E</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcDelMthPvdrMgd" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcDelMthPvdrMgd" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:lbl_svcDelMthPvdrMgd" for="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcDelMthPvdrMgd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:txt_lbl_svcDelMthPvdrMgd" class="outputText">Provider managed</span></label> </div> </div> </div> <div class="pph"> <p><span class="outputText">Specify whether the service may be provided by <span class="outputTextNB em">(check each that applies)</span>: </span> <div class="firstIndent"> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcPvdLegResp" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcPvdLegResp" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:lbl_svcPvdLegResp" for="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcPvdLegResp" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:txt_lbl_svcPvdLegResp" class="outputText">Legally Responsible Person</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcPvdRel" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcPvdRel" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:lbl_svcPvdRel" for="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcPvdRel" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:txt_lbl_svcPvdRel" class="outputText">Relative</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcPvdLegGrd" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcPvdLegGrd" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:lbl_svcPvdLegGrd" for="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:svcPvdLegGrd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:txt_lbl_svcPvdLegGrd" class="outputText">Legal Guardian</span></label> </div> </div> </div> <div class="pph"> <label id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:lbl_dtProviderTypes" for="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypes" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:txt_lbl_dtProviderTypes" class="outputText">Provider Specifications:</span></label> </div> <table id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypes" class="dtServices firstIndent" border="1" cellpadding="2" cellspacing="0" summary="dynamic table for provider specifications" ><thead ><tr ><th scope="col" ><span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypes:hdrProvCat" class="outputText">Provider Category</span></th><th scope="col" ><span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypes:hdrProvTyp" class="outputText">Provider Type Title</span></th></tr> </thead><tbody > <tr ><td ><input id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypeID" type="text" name="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypeID" value="220800" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypName" class="outputText">Agency</span></td> <td ><span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypes:0:pvdTypeName" class="outputText" style="width: 100%;">Care Management Agency</span></td> </tr> </tbody> </table> <table id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail" class="nstTableX" summary="detail table for provider specifications print." ><tbody > <tr ><td > <H2 id="pageTitle">Appendix C: Participant Services</H2> <H3 id="pageSubTitle">C-1/C-3: Provider Specifications for Service</H3> <div id='rtnNavTop' class='pph'> </div> <div> <div class="underline"> <div class="firstIndent"> <span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceTypelbl" class="outputText">Service Type: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceType" class="outputText">Statutory Service</span> </div> <div class="firstIndent"> <span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceNamelbl" class="outputText">Service Name: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceName" class="outputText">Care Management</span> </div> </div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdCat" for="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdCat" class="outputText">Provider Category:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" name="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" size="1" disabled="disabled"> <option value="0">Individual</option> <option value="1" selected="selected">Agency</option> </select> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdTypeName" for="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdTypeName" class="outputText">Provider Type:</span></label> </div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdTypeName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" name="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" class="inputTextarea" readonly="readonly">Care Management Agency</textarea></span> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txtProvQual" class="outputText">Provider Qualifications</span> </div> <div class="firstIndent"> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualLic" for="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualLic1" class="outputText">License </span><span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualLic2" class="outputTextNB em">(specify):</span></label> </div> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualLic"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" name="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" class="inputTextarea" readonly="readonly">The care manager who conducts the assessments, develops care plans and provides ongoing monitoring shall be either a registered nurse licensed in the state where care management services are provided or a social services worker who is a graduate of an accredited four-year college or university.</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualCert" for="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualCert1" class="outputText">Certificate </span><span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualCert2" class="outputTextNB em">(specify):</span></label> </div> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualCert"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" name="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" class="inputTextarea" readonly="readonly"></textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualOthStd" for="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualOthStd1" class="outputText">Other Standard </span><span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualOthStd2" class="outputTextNB em">(specify):</span></label> </div> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualOthStd"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" name="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" class="inputTextarea" readonly="readonly">The nurse or social services worker shall have a minimum of two years of experience in health care or human services. A bachelors degree in nursing, health, social work, gerontology or a related field may be substituted for one year of experience. Care managers shall have the following additional qualifications: demonstrated interviewing skills which include the professional judgment to probe as necessary to uncover underlying concerns of the applicants; demonstrated ability to establish and maintain empathic relationships; experience in conducting social and health assessments; knowledge of human behavior, family/caregiver dynamics, human development and disabilities; awareness of community resources and services; the ability to understand and apply complex service reimbursement issues; and the ability to evaluate, negotiate and plan for the costs of care options.</textarea></span> </div> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txtVerProvQual" class="outputText">Verification of Provider Qualifications</span> </div> <div class="firstIndent"> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdVrfEnt" for="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdVrfEnt" class="outputText">Entity Responsible for Verification:</span></label> </div> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdVrfEnt"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" name="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" class="inputTextarea" readonly="readonly">The Access Agency is responsible to ensure that employees meet the requirements specified in 17b-342-1(h)(1)(A). Department staff audit the Access Agencies for compliance with employee qualifications.</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdVrfFreq" for="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdVrfFreq" class="outputText">Frequency of Verification:</span></label> </div> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdVrfFreq"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" name="svapdxC1_1_prnt:dtServicesPrnt:0:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" class="inputTextarea" readonly="readonly">At the time of annual evaluation</textarea></span> </div> </div> </div> <table width="100%" style="margin-top: 10px"> <tr> <td width="50%" align="left"> </td> <td width="50%" align="right"> </td> </tr> </table> </td> </tr> </tbody> </table> <div class="pph"> </div> <table width="100%" style="margin: 10px 0;" id="TblSvcNavBottom"> <tr> <td width="50%" align="left"> </td> <td width="50%" align="right"> </td> </tr> </table> </td> </tr> <tr ><td > <LINK rel="stylesheet" type="text/css" href="/WMS/theme/twoColTable.css" media="print,screen"> <H2 id="pageTitle">Appendix C: Participant Services</H2> <H3 id="pageSubTitle">C-1/C-3: Service Specification</H3> <table width="100%" style="margin: 10px 0;" id="TblSvcNavTop"> <tr> <td width="50%" align="left"> </td> <td width="50%" align="right"> </td> </tr> </table> <div class="pph"> <span class="outputTextNB"> State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable). </span> </div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:lbl_svcType" for="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcType" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:txt_lbl_svcType" class="outputText">Service Type:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcType" name="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcType" size="1" onchange="return callSave(this, event);" disabled="disabled"> <option value="0">Statutory Service</option> <option value="1">Extended State Plan Service</option> <option value="2" selected="selected">Supports for Participant Direction</option> <option value="3">Other Service</option> </select> <div class="outputTextNB">The waiver provides for participant direction of services as specified in Appendix E. Indicate whether the waiver includes the following supports or other supports for participant direction.</div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:lbl_PDsvcName" for="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:PDsvcName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:txt_lbl_PDsvcName" class="outputText">Support for Participant Direction:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:PDsvcName" name="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:PDsvcName" size="1" disabled="disabled"> <option value="18" selected="selected">Information and Assistance in Support of Participant Direction</option> <option value="19">Financial Management Services</option> <option value="20">Other Supports for Participant Direction</option> </select> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:label1" for="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcAltName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:lblAlternateServiceTitle" class="outputText">Alternate Service Title (if any):</span></label> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:panel_svcAltName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcAltName" name="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcAltName" class="inputTextarea" readonly="readonly">Independent Support Broker</textarea></span> </div> </div> <div Class="pph"> <p class="outputText">HCBS Taxonomy:</p> <div class="firstIndent"> <div id="tblSummaryInfo" style="clear:both;"> <div class="rowContact"> <div class="leftCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:lbl_svcTaxCat1" for="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcTaxCat1" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:txt_lbl_svcTaxCat1" class="outputText">Category 1:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcTaxCat1" name="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcTaxCat1" class="selectOneMenuLong" size="1" onchange="document.getElementById('template:svapdxC1_1a:svcTaxSubCat1').value='99';return callSave(this, event);" disabled="disabled"> <option value="01">01 Case Management</option> <option value="02">02 Round-the-Clock Services</option> <option value="03">03 Supported Employment</option> <option value="04">04 Day Services</option> <option value="05">05 Nursing</option> <option value="06">06 Home Delivered Meals</option> <option value="07">07 Rent and Food Expenses for Live-In Caregiver</option> <option value="08">08 Home-Based Services</option> <option value="09">09 Caregiver Support</option> <option value="10">10 Other Mental Health and Behavioral Services</option> <option value="11">11 Other Health and Therapeutic Services</option> <option value="12">12 Services Supporting Self-Direction</option> <option value="13">13 Participant Training</option> <option value="14">14 Equipment, Technology, and Modifications</option> <option value="15">15 Non-Medical Transportation</option> <option value="16">16 Community Transition Services</option> <option value="17">17 Other Services</option> <option value="99" selected="selected"> </option> </select> </div> <div class="rightCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:lbl_svcTaxSubCat1" for="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcTaxSubCat1" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:txt_lbl_svcTaxSubCat1" class="outputText">Sub-Category 1:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcTaxSubCat1" name="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcTaxSubCat1" class="selectOneMenuLong" size="1" disabled="disabled"> <option value="99" selected="selected"> </option> </select> </div> </div> <div class="rowContact"> <div class="leftCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:lbl_taxCat2" for="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcTaxCat2" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:txt_lbl_taxCat2" class="outputText">Category 2:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcTaxCat2" name="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcTaxCat2" class="selectOneMenuLong" size="1" onchange="document.getElementById('template:svapdxC1_1a:svcTaxSubCat2').value='99';return callSave(this, event);" disabled="disabled"> <option value="01">01 Case Management</option> <option value="02">02 Round-the-Clock Services</option> <option value="03">03 Supported Employment</option> <option value="04">04 Day Services</option> <option value="05">05 Nursing</option> <option value="06">06 Home Delivered Meals</option> <option value="07">07 Rent and Food Expenses for Live-In Caregiver</option> <option value="08">08 Home-Based Services</option> <option value="09">09 Caregiver Support</option> <option value="10">10 Other Mental Health and Behavioral Services</option> <option value="11">11 Other Health and Therapeutic Services</option> <option value="12">12 Services Supporting Self-Direction</option> <option value="13">13 Participant Training</option> <option value="14">14 Equipment, Technology, and Modifications</option> <option value="15">15 Non-Medical Transportation</option> <option value="16">16 Community Transition Services</option> <option value="17">17 Other Services</option> <option value="99" selected="selected"> </option> </select> </div> <div class="rightCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:lbl_taxSubCat2" for="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcTaxSubCat2" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:txt_lbl_taxSubCat2" class="outputText">Sub-Category 2:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcTaxSubCat2" name="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcTaxSubCat2" class="selectOneMenuLong" size="1" disabled="disabled"> <option value="99" selected="selected"> </option> </select> </div> </div> <div class="rowContact"> <div class="leftCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:lbl_taxCat3" for="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcTaxCat3" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:txt_lbl_taxCat3" class="outputText">Category 3:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcTaxCat3" name="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcTaxCat3" class="selectOneMenuLong" size="1" onchange="document.getElementById('template:svapdxC1_1a:svcTaxSubCat3').value='99';return callSave(this, event);" disabled="disabled"> <option value="01">01 Case Management</option> <option value="02">02 Round-the-Clock Services</option> <option value="03">03 Supported Employment</option> <option value="04">04 Day Services</option> <option value="05">05 Nursing</option> <option value="06">06 Home Delivered Meals</option> <option value="07">07 Rent and Food Expenses for Live-In Caregiver</option> <option value="08">08 Home-Based Services</option> <option value="09">09 Caregiver Support</option> <option value="10">10 Other Mental Health and Behavioral Services</option> <option value="11">11 Other Health and Therapeutic Services</option> <option value="12">12 Services Supporting Self-Direction</option> <option value="13">13 Participant Training</option> <option value="14">14 Equipment, Technology, and Modifications</option> <option value="15">15 Non-Medical Transportation</option> <option value="16">16 Community Transition Services</option> <option value="17">17 Other Services</option> <option value="99" selected="selected"> </option> </select> </div> <div class="rightCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:lbl_taxSubCat3" for="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcTaxSubCat3" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:txt_lbl_taxSubCat3" class="outputText">Sub-Category 3:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcTaxSubCat3" name="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcTaxSubCat3" class="selectOneMenuLong" size="1" disabled="disabled"> <option value="99" selected="selected"> </option> </select> </div> </div> <div class="rowContact"> <div class="leftCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:lbl_taxCat4" for="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcTaxCat4" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:txt_lbl_taxCat4" class="outputText">Category 4:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcTaxCat4" name="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcTaxCat4" class="selectOneMenuLong" size="1" onchange="document.getElementById('template:svapdxC1_1a:svcTaxSubCat4').value='99';return callSave(this, event);" disabled="disabled"> <option value="01">01 Case Management</option> <option value="02">02 Round-the-Clock Services</option> <option value="03">03 Supported Employment</option> <option value="04">04 Day Services</option> <option value="05">05 Nursing</option> <option value="06">06 Home Delivered Meals</option> <option value="07">07 Rent and Food Expenses for Live-In Caregiver</option> <option value="08">08 Home-Based Services</option> <option value="09">09 Caregiver Support</option> <option value="10">10 Other Mental Health and Behavioral Services</option> <option value="11">11 Other Health and Therapeutic Services</option> <option value="12">12 Services Supporting Self-Direction</option> <option value="13">13 Participant Training</option> <option value="14">14 Equipment, Technology, and Modifications</option> <option value="15">15 Non-Medical Transportation</option> <option value="16">16 Community Transition Services</option> <option value="17">17 Other Services</option> <option value="99" selected="selected"> </option> </select> </div> <div class="rightCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:lbl_taxSubCat4" for="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcTaxSubCat4" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:txt_lbl_taxSubCat4" class="outputText">Sub-Category 4:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcTaxSubCat4" name="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcTaxSubCat4" class="selectOneMenuLong" size="1" disabled="disabled"> <option value="99" selected="selected"> </option> </select> </div> </div> </div> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:lbl_svcDef" for="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcDef" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:lbl_txt_svcDef1" class="outputText">Service Definition</span><span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:lbl_txt_svcDef2" class="outputTextNB em"> (Scope):</span></label> </div> <div></div> <div Class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:panel_svcDef"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcDef" name="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcDef" class="inputTextarea" readonly="readonly">Support and Consultation provided to individuals and/or their families to assist them in directing their own supports. This service is limited to those who direct their own supports. The services included are: Assistance with developing a natural community support network; Support with and training on how to hire and train staff; Training and support with managing staff; Accessing community activities and services, including helping the individual and family with the coordination of needed services;. Developing and maintaining an emergency backup plan; Self advocacy training and support.Service is available to participants who have fully utilized the $500 benefit available under the Medicaid State plan. (1915k)</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:lbl_svcLimDscr" for="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcLimDscr" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:txt_lbl_svcLimDscr" class="outputText">Specify applicable (if any) limits on the amount, frequency, or duration of this service:</span></label> </div> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:panel_svcLimDscr"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcLimDscr" name="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcLimDscr" class="inputTextarea" readonly="readonly">The total cost of the service cannot exceed 10% of the average monthly service plan.</textarea></span> </div> </div> <div Class="pph"> <p class="outputTextNB"><strong>Service Delivery Method </strong> <em>(check each that applies)</em>: </p> <div class="firstIndent"> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcDelMthPtcDir" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcDelMthPtcDir" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:lbl_svcDelMthPtcDir" for="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcDelMthPtcDir" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:txt_lbl_svcDelMthPtcDir" class="outputText">Participant-directed as specified in Appendix E</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcDelMthPvdrMgd" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcDelMthPvdrMgd" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:lbl_svcDelMthPvdrMgd" for="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcDelMthPvdrMgd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:txt_lbl_svcDelMthPvdrMgd" class="outputText">Provider managed</span></label> </div> </div> </div> <div class="pph"> <p><span class="outputText">Specify whether the service may be provided by <span class="outputTextNB em">(check each that applies)</span>: </span> <div class="firstIndent"> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcPvdLegResp" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcPvdLegResp" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:lbl_svcPvdLegResp" for="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcPvdLegResp" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:txt_lbl_svcPvdLegResp" class="outputText">Legally Responsible Person</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcPvdRel" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcPvdRel" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:lbl_svcPvdRel" for="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcPvdRel" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:txt_lbl_svcPvdRel" class="outputText">Relative</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcPvdLegGrd" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcPvdLegGrd" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:lbl_svcPvdLegGrd" for="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:svcPvdLegGrd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:txt_lbl_svcPvdLegGrd" class="outputText">Legal Guardian</span></label> </div> </div> </div> <div class="pph"> <label id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:lbl_dtProviderTypes" for="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypes" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:txt_lbl_dtProviderTypes" class="outputText">Provider Specifications:</span></label> </div> <table id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypes" class="dtServices firstIndent" border="1" cellpadding="2" cellspacing="0" summary="dynamic table for provider specifications" ><thead ><tr ><th scope="col" ><span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypes:hdrProvCat" class="outputText">Provider Category</span></th><th scope="col" ><span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypes:hdrProvTyp" class="outputText">Provider Type Title</span></th></tr> </thead><tbody > <tr ><td ><input id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypeID" type="text" name="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypeID" value="212288" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypName" class="outputText">Agency</span></td> <td ><span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypes:0:pvdTypeName" class="outputText" style="width: 100%;">Community Agency Provider</span></td> </tr> <tr ><td ><input id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypes:1:providerTypeID" type="text" name="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypes:1:providerTypeID" value="212287" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypes:1:providerTypName" class="outputText">Individual</span></td> <td ><span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypes:1:pvdTypeName" class="outputText" style="width: 100%;">Individual Private Provider</span></td> </tr> </tbody> </table> <table id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail" class="nstTableX" summary="detail table for provider specifications print." ><tbody > <tr ><td > <H2 id="pageTitle">Appendix C: Participant Services</H2> <H3 id="pageSubTitle">C-1/C-3: Provider Specifications for Service</H3> <div id='rtnNavTop' class='pph'> </div> <div> <div class="underline"> <div class="firstIndent"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceTypelbl" class="outputText">Service Type: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceType" class="outputText">Supports for Participant Direction</span> </div> <div class="firstIndent"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceNamelbl" class="outputText">Service Name: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceName" class="outputText">Independent Support Broker</span> </div> </div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdCat" for="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdCat" class="outputText">Provider Category:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" name="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" size="1" disabled="disabled"> <option value="0">Individual</option> <option value="1" selected="selected">Agency</option> </select> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdTypeName" for="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdTypeName" class="outputText">Provider Type:</span></label> </div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdTypeName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" name="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" class="inputTextarea" readonly="readonly">Community Agency Provider</textarea></span> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txtProvQual" class="outputText">Provider Qualifications</span> </div> <div class="firstIndent"> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualLic" for="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualLic1" class="outputText">License </span><span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualLic2" class="outputTextNB em">(specify):</span></label> </div> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualLic"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" name="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" class="inputTextarea" readonly="readonly"></textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualCert" for="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualCert1" class="outputText">Certificate </span><span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualCert2" class="outputTextNB em">(specify):</span></label> </div> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualCert"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" name="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" class="inputTextarea" readonly="readonly"></textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualOthStd" for="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualOthStd1" class="outputText">Other Standard </span><span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualOthStd2" class="outputTextNB em">(specify):</span></label> </div> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualOthStd"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" name="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" class="inputTextarea" readonly="readonly">The agency will ensure that employees meet the following qualifications: -21 yrs of age - criminal background check -registry check -demonstrated ability, experience and/or education to assist the individual and/or family in the hiring,management of personal care assistance and with other community services detailed in the participant's plan. - Demonstrate competence in knowledge of DSS policies and procedures: abuse/neglect; incident reporting; human rights and confidentiality;handling emergencies, prevention of abuse, neglect or exploitation, demonstrate understanding of the role of the service, of advocacy, person-centered planning, and community services -demonstrate understanding of self-hiring protocols and DSS fiscal management policies - Other qualifications as determined by the participant.</textarea></span> </div> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txtVerProvQual" class="outputText">Verification of Provider Qualifications</span> </div> <div class="firstIndent"> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdVrfEnt" for="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdVrfEnt" class="outputText">Entity Responsible for Verification:</span></label> </div> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdVrfEnt"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" name="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" class="inputTextarea" readonly="readonly">Fiscal intermediary</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdVrfFreq" for="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdVrfFreq" class="outputText">Frequency of Verification:</span></label> </div> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdVrfFreq"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" name="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" class="inputTextarea" readonly="readonly">prior to initiation of services and every 2 years thereafter</textarea></span> </div> </div> </div> <table width="100%" style="margin-top: 10px"> <tr> <td width="50%" align="left"> </td> <td width="50%" align="right"> </td> </tr> </table> </td> </tr> <tr ><td > <H2 id="pageTitle">Appendix C: Participant Services</H2> <H3 id="pageSubTitle">C-1/C-3: Provider Specifications for Service</H3> <div id='rtnNavTop' class='pph'> </div> <div> <div class="underline"> <div class="firstIndent"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_serviceTypelbl" class="outputText">Service Type: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_serviceType" class="outputText">Supports for Participant Direction</span> </div> <div class="firstIndent"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_serviceNamelbl" class="outputText">Service Name: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_serviceName" class="outputText">Independent Support Broker</span> </div> </div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdCat" for="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdCat" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_lbl_pvdCat" class="outputText">Provider Category:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdCat" name="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdCat" size="1" disabled="disabled"> <option value="0" selected="selected">Individual</option> <option value="1">Agency</option> </select> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdTypeName" for="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdTypeName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_lbl_pvdTypeName" class="outputText">Provider Type:</span></label> </div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:panel_pvdTypeName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdTypeName" name="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdTypeName" class="inputTextarea" readonly="readonly">Individual Private Provider</textarea></span> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txtProvQual" class="outputText">Provider Qualifications</span> </div> <div class="firstIndent"> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdQualLic" for="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualLic" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_lbl_pvdQualLic1" class="outputText">License </span><span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_lbl_pvdQualLic2" class="outputTextNB em">(specify):</span></label> </div> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:panel_pvdQualLic"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualLic" name="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualLic" class="inputTextarea" readonly="readonly"></textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdQualCert" for="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualCert" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_lbl_pvdQualCert1" class="outputText">Certificate </span><span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_lbl_pvdQualCert2" class="outputTextNB em">(specify):</span></label> </div> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:panel_pvdQualCert"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualCert" name="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualCert" class="inputTextarea" readonly="readonly"></textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdQualOthStd" for="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualOthStd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_lbl_pvdQualOthStd1" class="outputText">Other Standard </span><span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_lbl_pvdQualOthStd2" class="outputTextNB em">(specify):</span></label> </div> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:panel_pvdQualOthStd"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualOthStd" name="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualOthStd" class="inputTextarea" readonly="readonly">The FI will verify that employees meet the following qualifications prior to enrollment: - 21 years of age - criminal background check - registry check - demonstrated ability, experience and/or education to assist the individual and/or family in the hiring,management of personal care assistance and with other community services detailed in the participant's plan - demonstrate competence in knowledge of DSS policies and procedures: abuse/neglect; incident reporting; human rights and confidentiality; handling emergencies; prevention of abuse, neglect or exploitation - demonstrate understanding of the role of the service, of advocacy, person-centered planning, and community services -demonstrate understanding of self-hiring protocols and DSS fiscal management policies - other qualifications as determined by the participant.</textarea></span> </div> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txtVerProvQual" class="outputText">Verification of Provider Qualifications</span> </div> <div class="firstIndent"> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdVrfEnt" for="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdVrfEnt" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_lbl_pvdVrfEnt" class="outputText">Entity Responsible for Verification:</span></label> </div> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:panel_pvdVrfEnt"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdVrfEnt" name="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdVrfEnt" class="inputTextarea" readonly="readonly">Fiscal Intermediary</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdVrfFreq" for="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdVrfFreq" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_lbl_pvdVrfFreq" class="outputText">Frequency of Verification:</span></label> </div> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:panel_pvdVrfFreq"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdVrfFreq" name="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdVrfFreq" class="inputTextarea" readonly="readonly">Prior to employment and ongoing checks against sanctioned lists</textarea></span> </div> </div> </div> <table width="100%" style="margin-top: 10px"> <tr> <td width="50%" align="left"> </td> <td width="50%" align="right"> </td> </tr> </table> </td> </tr> </tbody> </table> <div class="pph"> </div> <table width="100%" style="margin: 10px 0;" id="TblSvcNavBottom"> <tr> <td width="50%" align="left"> </td> <td width="50%" align="right"> </td> </tr> </table> </td> </tr> <tr ><td > <LINK rel="stylesheet" type="text/css" href="/WMS/theme/twoColTable.css" media="print,screen"> <H2 id="pageTitle">Appendix C: Participant Services</H2> <H3 id="pageSubTitle">C-1/C-3: Service Specification</H3> <table width="100%" style="margin: 10px 0;" id="TblSvcNavTop"> <tr> <td width="50%" align="left"> </td> <td width="50%" align="right"> </td> </tr> </table> <div class="pph"> <span class="outputTextNB"> State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable). </span> </div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:lbl_svcType" for="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcType" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:txt_lbl_svcType" class="outputText">Service Type:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcType" name="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcType" size="1" onchange="return callSave(this, event);" disabled="disabled"> <option value="0">Statutory Service</option> <option value="1">Extended State Plan Service</option> <option value="2">Supports for Participant Direction</option> <option value="3" selected="selected">Other Service</option> </select> <div class="outputTextNB">As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.</div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:label1" for="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcAltName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:lblUserServiceTitle" class="outputText">Service Title:</span></label> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:panel_svcAltName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcAltName" name="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcAltName" class="inputTextarea" readonly="readonly">Adult Family Living/Foster Care</textarea></span> </div> </div> <div Class="pph"> <p class="outputText">HCBS Taxonomy:</p> <div class="firstIndent"> <div id="tblSummaryInfo" style="clear:both;"> <div class="rowContact"> <div class="leftCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:lbl_svcTaxCat1" for="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcTaxCat1" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:txt_lbl_svcTaxCat1" class="outputText">Category 1:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcTaxCat1" name="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcTaxCat1" class="selectOneMenuLong" size="1" onchange="document.getElementById('template:svapdxC1_1a:svcTaxSubCat1').value='99';return callSave(this, event);" disabled="disabled"> <option value="01">01 Case Management</option> <option value="02">02 Round-the-Clock Services</option> <option value="03">03 Supported Employment</option> <option value="04">04 Day Services</option> <option value="05">05 Nursing</option> <option value="06">06 Home Delivered Meals</option> <option value="07">07 Rent and Food Expenses for Live-In Caregiver</option> <option value="08">08 Home-Based Services</option> <option value="09">09 Caregiver Support</option> <option value="10">10 Other Mental Health and Behavioral Services</option> <option value="11">11 Other Health and Therapeutic Services</option> <option value="12">12 Services Supporting Self-Direction</option> <option value="13">13 Participant Training</option> <option value="14">14 Equipment, Technology, and Modifications</option> <option value="15">15 Non-Medical Transportation</option> <option value="16">16 Community Transition Services</option> <option value="17">17 Other Services</option> <option value="99" selected="selected"> </option> </select> </div> <div class="rightCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:lbl_svcTaxSubCat1" for="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcTaxSubCat1" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:txt_lbl_svcTaxSubCat1" class="outputText">Sub-Category 1:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcTaxSubCat1" name="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcTaxSubCat1" class="selectOneMenuLong" size="1" disabled="disabled"> <option value="99" selected="selected"> </option> </select> </div> </div> <div class="rowContact"> <div class="leftCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:lbl_taxCat2" for="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcTaxCat2" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:txt_lbl_taxCat2" class="outputText">Category 2:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcTaxCat2" name="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcTaxCat2" class="selectOneMenuLong" size="1" onchange="document.getElementById('template:svapdxC1_1a:svcTaxSubCat2').value='99';return callSave(this, event);" disabled="disabled"> <option value="01">01 Case Management</option> <option value="02">02 Round-the-Clock Services</option> <option value="03">03 Supported Employment</option> <option value="04">04 Day Services</option> <option value="05">05 Nursing</option> <option value="06">06 Home Delivered Meals</option> <option value="07">07 Rent and Food Expenses for Live-In Caregiver</option> <option value="08">08 Home-Based Services</option> <option value="09">09 Caregiver Support</option> <option value="10">10 Other Mental Health and Behavioral Services</option> <option value="11">11 Other Health and Therapeutic Services</option> <option value="12">12 Services Supporting Self-Direction</option> <option value="13">13 Participant Training</option> <option value="14">14 Equipment, Technology, and Modifications</option> <option value="15">15 Non-Medical Transportation</option> <option value="16">16 Community Transition Services</option> <option value="17">17 Other Services</option> <option value="99" selected="selected"> </option> </select> </div> <div class="rightCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:lbl_taxSubCat2" for="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcTaxSubCat2" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:txt_lbl_taxSubCat2" class="outputText">Sub-Category 2:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcTaxSubCat2" name="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcTaxSubCat2" class="selectOneMenuLong" size="1" disabled="disabled"> <option value="99" selected="selected"> </option> </select> </div> </div> <div class="rowContact"> <div class="leftCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:lbl_taxCat3" for="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcTaxCat3" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:txt_lbl_taxCat3" class="outputText">Category 3:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcTaxCat3" name="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcTaxCat3" class="selectOneMenuLong" size="1" onchange="document.getElementById('template:svapdxC1_1a:svcTaxSubCat3').value='99';return callSave(this, event);" disabled="disabled"> <option value="01">01 Case Management</option> <option value="02">02 Round-the-Clock Services</option> <option value="03">03 Supported Employment</option> <option value="04">04 Day Services</option> <option value="05">05 Nursing</option> <option value="06">06 Home Delivered Meals</option> <option value="07">07 Rent and Food Expenses for Live-In Caregiver</option> <option value="08">08 Home-Based Services</option> <option value="09">09 Caregiver Support</option> <option value="10">10 Other Mental Health and Behavioral Services</option> <option value="11">11 Other Health and Therapeutic Services</option> <option value="12">12 Services Supporting Self-Direction</option> <option value="13">13 Participant Training</option> <option value="14">14 Equipment, Technology, and Modifications</option> <option value="15">15 Non-Medical Transportation</option> <option value="16">16 Community Transition Services</option> <option value="17">17 Other Services</option> <option value="99" selected="selected"> </option> </select> </div> <div class="rightCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:lbl_taxSubCat3" for="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcTaxSubCat3" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:txt_lbl_taxSubCat3" class="outputText">Sub-Category 3:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcTaxSubCat3" name="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcTaxSubCat3" class="selectOneMenuLong" size="1" disabled="disabled"> <option value="99" selected="selected"> </option> </select> </div> </div> <div class="rowContact"> <div class="leftCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:lbl_taxCat4" for="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcTaxCat4" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:txt_lbl_taxCat4" class="outputText">Category 4:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcTaxCat4" name="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcTaxCat4" class="selectOneMenuLong" size="1" onchange="document.getElementById('template:svapdxC1_1a:svcTaxSubCat4').value='99';return callSave(this, event);" disabled="disabled"> <option value="01">01 Case Management</option> <option value="02">02 Round-the-Clock Services</option> <option value="03">03 Supported Employment</option> <option value="04">04 Day Services</option> <option value="05">05 Nursing</option> <option value="06">06 Home Delivered Meals</option> <option value="07">07 Rent and Food Expenses for Live-In Caregiver</option> <option value="08">08 Home-Based Services</option> <option value="09">09 Caregiver Support</option> <option value="10">10 Other Mental Health and Behavioral Services</option> <option value="11">11 Other Health and Therapeutic Services</option> <option value="12">12 Services Supporting Self-Direction</option> <option value="13">13 Participant Training</option> <option value="14">14 Equipment, Technology, and Modifications</option> <option value="15">15 Non-Medical Transportation</option> <option value="16">16 Community Transition Services</option> <option value="17">17 Other Services</option> <option value="99" selected="selected"> </option> </select> </div> <div class="rightCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:lbl_taxSubCat4" for="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcTaxSubCat4" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:txt_lbl_taxSubCat4" class="outputText">Sub-Category 4:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcTaxSubCat4" name="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcTaxSubCat4" class="selectOneMenuLong" size="1" disabled="disabled"> <option value="99" selected="selected"> </option> </select> </div> </div> </div> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:lbl_svcDef" for="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcDef" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:lbl_txt_svcDef1" class="outputText">Service Definition</span><span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:lbl_txt_svcDef2" class="outputTextNB em"> (Scope):</span></label> </div> <div></div> <div Class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:panel_svcDef"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcDef" name="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcDef" class="inputTextarea" readonly="readonly">Personal care and supportive services (homemaker, chore, attendant services, meal preparation) that are furnished to waiver participants who reside in a private home by a principal caregiver who lives in the home. Adult Family Living/Foster Care is furnished to adults who receive these services in conjunction with residing in the home. Service includes 24 hour response capability to meet scheduled or unpredictable resident needs to provide supervision, safety and security based on ADL, IADL, cognitive or behavioral needs. Service allocation is based on ADL, IADL, cognitive or behavioral needs. Services also include social and recreational activities and cueing or reminders to take medications. Separate payment will not be made for homemaker or chore services furnished to an individual receiving adult foster care services, since these are integral to and inherent in the provision of Adult Family Living/Foster Care services. Edits in the MMIS system do not allow these services to be billed when Adult Family Living/Foster Care is in place as a service. Four classifications of Adult Family Living/Foster Care service will be available under this Waiver: Level 1: service provided to individuals who because of their impairments, require supervision on a daily basis and require cueing or supervision to perform ADLs and may also have cognitive or behavioral challenges Level 2: services provided to individuals who require hands on assistance to perform 2 ADLs on a daily basis. Level 3: services provided to individuals who require hands on assistance to perform 3 or more ADLs or 2 ADLs and co-occurring assistance for the management of challenging behaviors or cognitive deficits. Level 4: services provided to individuals who require hands on assistance to perform 4 or more ADLs or 3 ADLs and co-occurring assistance for the management of challenging behaviors or cognitive deficits. The agency that provides the Adult Family Living/Foster Care service will supervise the supports delivered by the direct care provider. This service may be provided in the home of either the care provider or the participant, whichever is preferable to the participant. The direct provider may be a relative of the client as long as they are not a legally liable relative. Adult Family Living/Foster Care is limited to no more than 4 participants in a home. The Adult Family LivingFoster Care provider may not administer medication but may supervise the participant's self-administration of medication. Payments made for Adult Family Living/Foster Care are not made for room and board, items of comfort or convenience, or the costs of home maintenance, upkeep and improvement. The methodology by which the costs of room and board are excluded from payments for Adult Family Living/Foster Care are described in Appendix I.</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:lbl_svcLimDscr" for="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcLimDscr" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:txt_lbl_svcLimDscr" class="outputText">Specify applicable (if any) limits on the amount, frequency, or duration of this service:</span></label> </div> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:panel_svcLimDscr"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcLimDscr" name="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcLimDscr" class="inputTextarea" readonly="readonly"></textarea></span> </div> </div> <div Class="pph"> <p class="outputTextNB"><strong>Service Delivery Method </strong> <em>(check each that applies)</em>: </p> <div class="firstIndent"> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcDelMthPtcDir" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcDelMthPtcDir" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:lbl_svcDelMthPtcDir" for="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcDelMthPtcDir" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:txt_lbl_svcDelMthPtcDir" class="outputText">Participant-directed as specified in Appendix E</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcDelMthPvdrMgd" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcDelMthPvdrMgd" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:lbl_svcDelMthPvdrMgd" for="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcDelMthPvdrMgd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:txt_lbl_svcDelMthPvdrMgd" class="outputText">Provider managed</span></label> </div> </div> </div> <div class="pph"> <p><span class="outputText">Specify whether the service may be provided by <span class="outputTextNB em">(check each that applies)</span>: </span> <div class="firstIndent"> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcPvdLegResp" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcPvdLegResp" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:lbl_svcPvdLegResp" for="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcPvdLegResp" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:txt_lbl_svcPvdLegResp" class="outputText">Legally Responsible Person</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcPvdRel" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcPvdRel" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:lbl_svcPvdRel" for="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcPvdRel" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:txt_lbl_svcPvdRel" class="outputText">Relative</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcPvdLegGrd" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcPvdLegGrd" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:lbl_svcPvdLegGrd" for="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:svcPvdLegGrd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:txt_lbl_svcPvdLegGrd" class="outputText">Legal Guardian</span></label> </div> </div> </div> <div class="pph"> <label id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:lbl_dtProviderTypes" for="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypes" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:txt_lbl_dtProviderTypes" class="outputText">Provider Specifications:</span></label> </div> <table id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypes" class="dtServices firstIndent" border="1" cellpadding="2" cellspacing="0" summary="dynamic table for provider specifications" ><thead ><tr ><th scope="col" ><span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypes:hdrProvCat" class="outputText">Provider Category</span></th><th scope="col" ><span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypes:hdrProvTyp" class="outputText">Provider Type Title</span></th></tr> </thead><tbody > <tr ><td ><input id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypeID" type="text" name="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypeID" value="200885" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypName" class="outputText">Agency</span></td> <td ><span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypes:0:pvdTypeName" class="outputText" style="width: 100%;">Provider Agency</span></td> </tr> </tbody> </table> <table id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail" class="nstTableX" summary="detail table for provider specifications print." ><tbody > <tr ><td > <H2 id="pageTitle">Appendix C: Participant Services</H2> <H3 id="pageSubTitle">C-1/C-3: Provider Specifications for Service</H3> <div id='rtnNavTop' class='pph'> </div> <div> <div class="underline"> <div class="firstIndent"> <span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceTypelbl" class="outputText">Service Type: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceType" class="outputText">Other Service</span> </div> <div class="firstIndent"> <span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceNamelbl" class="outputText">Service Name: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceName" class="outputText">Adult Family Living/Foster Care</span> </div> </div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdCat" for="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdCat" class="outputText">Provider Category:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" name="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" size="1" disabled="disabled"> <option value="0">Individual</option> <option value="1" selected="selected">Agency</option> </select> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdTypeName" for="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdTypeName" class="outputText">Provider Type:</span></label> </div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdTypeName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" name="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" class="inputTextarea" readonly="readonly">Provider Agency</textarea></span> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txtProvQual" class="outputText">Provider Qualifications</span> </div> <div class="firstIndent"> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualLic" for="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualLic1" class="outputText">License </span><span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualLic2" class="outputTextNB em">(specify):</span></label> </div> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualLic"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" name="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" class="inputTextarea" readonly="readonly">n/a</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualCert" for="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualCert1" class="outputText">Certificate </span><span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualCert2" class="outputTextNB em">(specify):</span></label> </div> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualCert"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" name="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" class="inputTextarea" readonly="readonly"></textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualOthStd" for="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualOthStd1" class="outputText">Other Standard </span><span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualOthStd2" class="outputTextNB em">(specify):</span></label> </div> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualOthStd"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" name="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" class="inputTextarea" readonly="readonly">In order to be an Adult Family Living/Foster Care provider setting, the provider agency must certify that the home is regularly maintained and that the interior floors, walls, ceiling and furnishings are clean and in good repair including the kitchen area, bathroom and participant&#8217;s bedroom, ventilation, heating, lighting and stairs. The home should conform to all applicable building codes, health and safety codes and ordinances and meet the participant&#8217;s need for privacy. The home should also be equipped with a fire extinguisher and an emergency first aid kit. It is the responsibility of the provider agency to ensure that the home meets all of these specifications. In addition, the agency is responsible to verify that the provider is at least 18 years of age, is in good health and able to follow written and verbal instruction, report changes in a participant&#8217;s condition, maintain confidentiality and complete record keeping requirements specified by the provider agency. The provider agency will provide nursing oversight/supervision of the provision of care by the Adult Family Living/Foster Care provider on a minimum of a bi-monthly basis. Their role will include orientation, competency evaluations in the provision of daily care and ongoing continuing education for the direct caregiver. The agency provider as well as the care manager are responsible to assure the health and safety needs of the participant are met. The direct caregiver will provide nutritionally balanced meals and healthy snacks each day to the waiver participant, as dictated by their medical/nutritional needs. The reimbursement rate does not include room and board. The payment for room and board costs are negotiated between the direct service provider and the waiver participant. The provider agency in order to be credentialed to provide Adult Family Living/Foster Care must provide evidence of an ability to certify that the individual home meets all of the requirements included in this description and can demonstrate an ability to monitor the delivery and quality of service provided to the waiver participant. The agency may also provide relief to the direct service provider or the care manager can provide relief through the provision of other waiver services. The provider agency bills the Access Agency which holds the provider agreement with the state which then pays the provider. The provider is then responsible to pay the direct caregiver.</textarea></span> </div> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txtVerProvQual" class="outputText">Verification of Provider Qualifications</span> </div> <div class="firstIndent"> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdVrfEnt" for="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdVrfEnt" class="outputText">Entity Responsible for Verification:</span></label> </div> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdVrfEnt"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" name="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" class="inputTextarea" readonly="readonly">Fiscal intermediary.</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdVrfFreq" for="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdVrfFreq" class="outputText">Frequency of Verification:</span></label> </div> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdVrfFreq"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" name="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" class="inputTextarea" readonly="readonly">At the initiation of service and biannually thereafter.</textarea></span> </div> </div> </div> <table width="100%" style="margin-top: 10px"> <tr> <td width="50%" align="left"> </td> <td width="50%" align="right"> </td> </tr> </table> </td> </tr> </tbody> </table> <div class="pph"> </div> <table width="100%" style="margin: 10px 0;" id="TblSvcNavBottom"> <tr> <td width="50%" align="left"> </td> <td width="50%" align="right"> </td> </tr> </table> </td> </tr> </tbody> </table> </div> <H2 id="pageTitle">Appendix C: Participant Services</H2> <H3 id="pageSubTitle">C-1: Summary of Services Covered <SPAN id="pageNumber">(2 of 2)</SPAN></H3> <OL class="alphaLC" start="2"> <LI> <div class="outputTextNB"> <strong>Provision of Case Management Services to Waiver Participants. </strong> Indicate how case management is furnished to waiver participants (<em>select one</em>): </div> <div class="noShow"><label><input id="svapdxC1_2:svcCsMgmt:3" type="radio" name="svapdxC1_2:svcCsMgmt" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> <div class="checkboxGroup"> <label><input id="svapdxC1_2:svcCsMgmt:1" type="radio" name="svapdxC1_2:svcCsMgmt" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;Not applicable</label> <span class="outputTextNB"> - Case management is not furnished as a distinct activity to waiver participants.</span> </div> <div class="checkboxGroup"> <label><input id="svapdxC1_2:svcCsMgmt:0" type="radio" name="svapdxC1_2:svcCsMgmt" checked="checked" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;Applicable</label> <span class="outputTextNB"> - Case management is furnished as a distinct activity to waiver participants.</span> </div> <div class="firstIndent"> <div class="outputTextNB em">Check each that applies:</div> <div class="checkboxGroup"> <input id="svapdxC1_2:svcCsMgmtSvc" type="checkbox" name="svapdxC1_2:svcCsMgmtSvc" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_2:lbl_svcCsMgmtSvc" for="svapdxC1_2:svcCsMgmtSvc" class="outputLabel"> <span id="svapdxC1_2:lbl_txt_svcCsMgmtSvc" class="outputText">As a waiver service defined in Appendix C-3.</span></label> <span class="outputTextNB em"> Do not complete item C-1-c.</span> </div> <div class="checkboxGroup"> <input id="svapdxC1_2:svcCsMgmtHcbs" type="checkbox" name="svapdxC1_2:svcCsMgmtHcbs" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_2:lbl_svcCsMgmtHcbs" for="svapdxC1_2:svcCsMgmtHcbs" class="outputLabel"> <span id="svapdxC1_2:lbl_txt_svcCsMgmtHcbs" class="outputText">As a Medicaid State plan service under &sect;1915(i) of the Act (HCBS as a State Plan Option).</span></label> <span class="outputTextNB em"> Complete item C-1-c.</span> </div> <div class="checkboxGroup"> <input id="svapdxC1_2:svcCsMgmtTrg" type="checkbox" name="svapdxC1_2:svcCsMgmtTrg" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_2:lbl_svcCsMgmtTrg" for="svapdxC1_2:svcCsMgmtTrg" class="outputLabel"> <span id="svapdxC1_2:lbl_txt_svcCsMgmtTrg" class="outputText">As a Medicaid State plan service under &sect;1915(g)(1) of the Act (Targeted Case Management).</span></label> <span class="outputTextNB em"> Complete item C-1-c.</span> </div> <div class="checkboxGroup"> <input id="svapdxC1_2:svcCsMgmtAdmin" type="checkbox" name="svapdxC1_2:svcCsMgmtAdmin" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_2:lbl_svcCsMgmtAdmin" for="svapdxC1_2:svcCsMgmtAdmin" class="outputLabel"> <span id="svapdxC1_2:lbl_txt_svcCsMgmtAdmin" class="outputText">As an administrative activity.</span></label> <span class="outputTextNB em"> Complete item C-1-c. </span><span class="noShow">NOTE: Pursuant to CMS-2237-IFC this selection is no longer available for 1915(c) waivers.</span> </div> <div class="noShow"> <input id="svapdxC1_2:svcCsMgmtNa" type="checkbox" name="svapdxC1_2:svcCsMgmtNa" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_2:lbl_svcCsMgmtNa" for="svapdxC1_2:svcCsMgmtNa" class="outputLabel"> <span id="svapdxC1_2:lbl_txt_svcCsMgmtNa" class="outputText">Not applicable - Case management is not furnished as a distinct activity to waiver participants.</span></label> <span class="outputTextNB em"> Do not complete item C-1-c.</span> </div> </div> <div class="checkboxGroup noShow"> <label><input id="svapdxC1_2:svcCsMgmt:2" type="radio" name="svapdxC1_2:svcCsMgmt" value="2" onclick="return callSave(this, event);" disabled="disabled" />&#160;None of the above apply</label> <span class="outputTextNB"> - Case management is furnished as a waiver service (Do not complete item C-1-c).</span> </div> </LI> <LI> <p> <strong>Delivery of Case Management Services.</strong> <label id="svapdxC1_2:lbl_svcCsMgmtEnt" for="svapdxC1_2:svcCsMgmtEnt" class="outputLabel"> <span id="svapdxC1_2:lbl_txt_svcCsMgmtEnt" class="outputTextNB">Specify the entity or entities that conduct case management functions on behalf of waiver participants:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxC1_2:svcCsMgmtEntChrCntLbl" for="svapdxC1_2:svcCsMgmtEntChrCnt" class="outputLabel"> <span id="svapdxC1_2:svcCsMgmtEntChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxC1_2:svcCsMgmtEntChrCnt" type="text" name="svapdxC1_2:svcCsMgmtEntChrCnt" class="chrCnt" size="6" /><span id="svapdxC1_2:svcCsMgmtEntChrCntMax" class="chrCnt"> out of 4000</span> </div> <div class="inputTextareaWA"> <span id="svapdxC1_2:panel_svcCsMgmtEnt"><textarea id="svapdxC1_2:svcCsMgmtEnt" name="svapdxC1_2:svcCsMgmtEnt" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </LI> </OL> <H2 id="pageTitle">Appendix C: Participant Services</H2> <H3 id="pageSubTitle">C-2: General Service Specifications <SPAN id="pageNumber">(1 of 3)</SPAN></H3> <OL class="alphaLC" start="1"> <LI> <p class="outputTextNB"> <strong>Criminal History and/or Background Investigations.</strong> <label id="svapdxC2_1:lbl_svcBckChkReq" for="svapdxC2_1:svcBckChkReq" class="outputLabel"> <span id="svapdxC2_1:lbl_txt_svcBckChkReq1" class="outputTextNB">Specify the State's policies concerning the conduct of criminal history and/or background investigations of individuals who provide waiver services </span><span id="svapdxC2_1:lbl_txt_svcBckChkReq2" class="outputTextNB me">(select one):</span></label> </p> <table id="svapdxC2_1:svcBckChkReq" class="selectOneRadio"> <tr> <td> <input type="radio" name="svapdxC2_1:svcBckChkReq" id="svapdxC2_1:svcBckChkReq:0" value="0" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxC2_1:svcBckChkReq:0"> No. Criminal history and/or background investigations are not required.</label></td> </tr> <tr> <td> <input type="radio" checked="checked" name="svapdxC2_1:svcBckChkReq" id="svapdxC2_1:svcBckChkReq:1" value="1" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxC2_1:svcBckChkReq:1"> Yes. Criminal history and/or background investigations are required.</label></td> </tr> </table> <div class="firstIndent"> <p class="outputTextNB"> <label id="svapdxC2_1:lbl_svcBckChkDscr" for="svapdxC2_1:svcBckChkDscr" class="outputLabel"> <span id="svapdxC2_1:lbl_txt_svcBckChkDscr" class="outputTextNB">Specify: (a) the types of positions (e.g., personal assistants, attendants) for which such investigations must be conducted; (b) the scope of such investigations (e.g., state, national); and, (c) the process for ensuring that mandatory investigations have been conducted. State laws, regulations and policies referenced in this description are available to CMS upon request through the Medicaid or the operating agency (if applicable):</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxC2_1:svcBckChkDscrChrCntLbl" for="svapdxC2_1:svcBckChkDscrChrCnt" class="outputLabel"> <span id="svapdxC2_1:svcBckChkDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxC2_1:svcBckChkDscrChrCnt" type="text" name="svapdxC2_1:svcBckChkDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxC2_1:svcBckChkDscrChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxC2_1:panel_svcBckChkDscr"><textarea id="svapdxC2_1:svcBckChkDscr" name="svapdxC2_1:svcBckChkDscr" class="inputTextarea" onkeyup="Count(this);" readonly="readonly">The fiscal intermediary conducts a criminal background check on all self directed service providers including the Independent Support Broker. Generally it is a state search but may be expanded to a national check if the person has lived out state. The department requires the fiscal intermediary to report quarterly on the number of pre-employment background checks completed and the outcome of those checks.</textarea></span> </div> </div> </LI> <LI> <p class="outputTextNB"> <strong>Abuse Registry Screening.</strong> <label id="svapdxC2_1:lbl_svcAbsRgsScrn" for="svapdxC2_1:svcAbsRgsScrn" class="outputLabel"> <span id="svapdxC2_1:lbl_txt_svcAbsRgsScrn1" class="outputTextNB">Specify whether the State requires the screening of individuals who provide waiver services through a State-maintained abuse registry </span><span id="svapdxC2_1:lbl_txt_svcAbsRgsScrn2" class="outputTextNB me">(select one):</span></label> </p> <table id="svapdxC2_1:svcAbsRgsScrn" class="selectOneRadio"> <tr> <td> <input type="radio" checked="checked" name="svapdxC2_1:svcAbsRgsScrn" id="svapdxC2_1:svcAbsRgsScrn:0" value="0" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxC2_1:svcAbsRgsScrn:0"> No. The State does not conduct abuse registry screening.</label></td> </tr> <tr> <td> <input type="radio" name="svapdxC2_1:svcAbsRgsScrn" id="svapdxC2_1:svcAbsRgsScrn:1" value="1" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxC2_1:svcAbsRgsScrn:1"> Yes. The State maintains an abuse registry and requires the screening of individuals through this registry.</label></td> </tr> </table> <div class="firstIndent"> <p class="outputTextNB"> <label id="svapdxC2_1:lbl_svcAbsRgsScrnDscr" for="svapdxC2_1:svcAbsRgsScrnDscr" class="outputLabel"> <span id="svapdxC2_1:lbl_txt_svcAbsRgsScrnDscr" class="outputTextNB">Specify: (a) the entity (entities) responsible for maintaining the abuse registry; (b) the types of positions for which abuse registry screenings must be conducted; and, (c) the process for ensuring that mandatory screenings have been conducted. State laws, regulations and policies referenced in this description are available to CMS upon request through the Medicaid agency or the operating agency (if applicable):</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxC2_1:svcAbsRgsScrnDscrChrCntLbl" for="svapdxC2_1:svcAbsRgsScrnDscrChrCnt" class="outputLabel"> <span id="svapdxC2_1:svcAbsRgsScrnDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxC2_1:svcAbsRgsScrnDscrChrCnt" type="text" name="svapdxC2_1:svcAbsRgsScrnDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxC2_1:svcAbsRgsScrnDscrChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxC2_1:panel_svcAbsRgsScrnDscr"><textarea id="svapdxC2_1:svcAbsRgsScrnDscr" name="svapdxC2_1:svcAbsRgsScrnDscr" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> </LI> </OL> <H2 id="pageTitle">Appendix C: Participant Services</H2> <H3 id="pageSubTitle">C-2: General Service Specifications <SPAN id="pageNumber">(2 of 3)</SPAN></H3> <OL class="alphaLC" start="3"> <LI><p> <span id="svapdxC2_2:lbl_txt_svcCvd1616e1" class="outputText">Services in Facilities Subject to &sect;1616(e) of the Social Security Act.</span><span id="svapdxC2_2:lbl_txt_svcCvd1616e2" class="outputTextNB em"> Select one:</span> </p> <table id="svapdxC2_2:svcCvd1616e" class="selectOneRadio"> <tr> <td> <input type="radio" checked="checked" name="svapdxC2_2:svcCvd1616e" id="svapdxC2_2:svcCvd1616e:0" value="0" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxC2_2:svcCvd1616e:0"> No. Home and community-based services under this waiver are not provided in facilities subject to &sect;1616(e) of the Act.</label></td> </tr> <tr> <td> <input type="radio" name="svapdxC2_2:svcCvd1616e" id="svapdxC2_2:svcCvd1616e:1" value="1" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxC2_2:svcCvd1616e:1"> Yes. Home and community-based services are provided in facilities subject to &sect;1616(e) of the Act. The standards that apply to each type of facility where waiver services are provided are available to CMS upon request through the Medicaid agency or the operating agency (if applicable).</label></td> </tr> </table> <div class="firstIndent"> </div> </LI> </OL> <div class="firstIndent"> </div> <H2 id="pageTitle">Appendix C: Participant Services</H2> <H3 id="pageSubTitle">C-2: General Service Specifications <SPAN id="pageNumber">(3 of 3)</SPAN></H3> <OL class="alphaLC" start="4"> <LI> <p class="outputTextNB"> <strong>Provision of Personal Care or Similar Services by Legally Responsible Individuals.</strong> A legally responsible individual is any person who has a duty under State law to care for another person and typically includes: (a) the parent (biological or adoptive) of a minor child or the guardian of a minor child who must provide care to the child or (b) a spouse of a waiver participant. Except at the option of the State and under extraordinary circumstances specified by the State, payment may not be made to a legally responsible individual for the provision of personal care or similar services that the legally responsible individual would ordinarily perform or be responsible to perform on behalf of a waiver participant. <em>Select one</em>: </p> <div class="checkboxGroup"><label><input id="svapdxC2_3:pcLegRspIndv:0" type="radio" name="svapdxC2_3:pcLegRspIndv" checked="checked" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;No. The State does not make payment to legally responsible individuals for furnishing personal care or similar services.</label></div> <div class="checkboxGroup"><label><input id="svapdxC2_3:pcLegRspIndv:1" type="radio" name="svapdxC2_3:pcLegRspIndv" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;Yes. The State makes payment to legally responsible individuals for furnishing personal care or similar services when they are qualified to provide the services.</label></div> <div class="firstIndent"> <p> <label id="svapdxC2_3:lbl_pcLegRspIndvDscr" for="svapdxC2_3:pcLegRspIndvDscr" class="outputLabel"> <span id="svapdxC2_3:lbl_txt_pcLegRspIndvDscr1" class="outputTextNB">Specify: (a) the legally responsible individuals who may be paid to furnish such services and the services they may provide; (b) State policies that specify the circumstances when payment may be authorized for the provision of </span><span id="svapdxC2_3:lbl_txt_pcLegRspIndvDscr2" class="outputText em"> extraordinary care</span><span id="svapdxC2_3:lbl_txt_pcLegRspIndvDscr3" class="outputTextNB"> by a legally responsible individual and how the State ensures that the provision of services by a legally responsible individual is in the best interest of the participant; and, (c) the controls that are employed to ensure that payments are made only for services rendered.</span><span id="svapdxC2_3:lbl_txt_pcLegRspIndvDscr4" class="outputTextNB em"> Also, specify in Appendix C-1/C-3 the personal care or similar services for which payment may be made to legally responsible individuals under the State policies specified here.</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxC2_3:pcLegRspIndvDscrChrCntLbl" for="svapdxC2_3:pcLegRspIndvDscrChrCnt" class="outputLabel"> <span id="svapdxC2_3:pcLegRspIndvDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxC2_3:pcLegRspIndvDscrChrCnt" type="text" name="svapdxC2_3:pcLegRspIndvDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxC2_3:pcLegRspIndvDscrChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxC2_3:panel_pcLegRspIndvDscr"><textarea id="svapdxC2_3:pcLegRspIndvDscr" name="svapdxC2_3:pcLegRspIndvDscr" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="noShow"><label><input id="svapdxC2_3:pcLegRspIndv:2" type="radio" name="svapdxC2_3:pcLegRspIndv" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </LI> <div class="checkboxGroup"> <table id="svapdxC2_3:cbSectionList" class="selectManyCheckbox"> <tr> <td> <input name="svapdxC2_3:cbSectionList" id="svapdxC2_3:cbSectionList:0" value="sd" type="checkbox" disabled="disabled" readonly="readonly" /><label for="svapdxC2_3:cbSectionList:0"> Self-directed</label></td> </tr> <tr> <td> <input name="svapdxC2_3:cbSectionList" id="svapdxC2_3:cbSectionList:1" value="ao" type="checkbox" disabled="disabled" readonly="readonly" /><label for="svapdxC2_3:cbSectionList:1"> Agency-operated</label></td> </tr> </table> <p class="checkboxGroup pph"> <!-- <input type="submit" value="Validate" id="svapdxC2_3:button1" name="svapdxC2_3:button1" class="commandExButton" /> --> </p> </div> <LI> <p class="outputTextNB"> <strong>Other State Policies Concerning Payment for Waiver Services Furnished by Relatives/Legal Guardians.</strong> Specify State policies concerning making payment to relatives/legal guardians for the provision of waiver services over and above the policies addressed in Item C-2-d. <em>Select one</em>: </p> <div class="checkboxGroup"><label><input id="svapdxC2_3:svcPolRelType:0" type="radio" name="svapdxC2_3:svcPolRelType" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;The State does not make payment to relatives/legal guardians for furnishing waiver services.</label></div> <div class="checkboxGroup"><label><input id="svapdxC2_3:svcPolRelType:1" type="radio" name="svapdxC2_3:svcPolRelType" checked="checked" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;The State makes payment to relatives/legal guardians under specific circumstances and only when the relative/guardian is qualified to furnish services.</label></div> <div class="firstIndent"> <p class="outputTextNB"> <label id="svapdxC2_3:lbl_svcPolRelCirc" for="svapdxC2_3:svcPolRelCirc" class="outputLabel"> <span id="svapdxC2_3:lbl_txt_svcPolRelCirc1" class="outputTextNB">Specify the specific circumstances under which payment is made, the types of relatives/legal guardians to whom payment may be made, and the services for which payment may be made. Specify the controls that are employed to ensure that payments are made only for services rendered.</span><span id="svapdxC2_3:lbl_txt_svcPolRelCirc2" class="outputTextNB em"> Also, specify in Appendix C-1/C-3 each waiver service for which payment may be made to relatives/legal guardians.</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxC2_3:svcPolRelCircChrCntLbl" for="svapdxC2_3:svcPolRelCircChrCnt" class="outputLabel"> <span id="svapdxC2_3:svcPolRelCircChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxC2_3:svcPolRelCircChrCnt" type="text" name="svapdxC2_3:svcPolRelCircChrCnt" class="chrCnt" size="6" /><span id="svapdxC2_3:svcPolRelCircChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxC2_3:panel_svcPolRelCirc"><textarea id="svapdxC2_3:svcPolRelCirc" name="svapdxC2_3:svcPolRelCirc" class="inputTextarea" onkeyup="Count(this);" readonly="readonly">The Department allows for an Adult Family Living/Foster Care direct service provider to be a family member. The Department does not pay legally liable relatives or relatives of Conservators of Person (COP) or Conservators of Estate (COE) to provide care. A COP is appointed by the Probate court to supervise the personal affairs of an individual including the arrangement for medical needs and ensuring the individual has nutritious meals, clothing, safe and adequate housing, and personal hygiene and is protected from physical abuse or harm. A COE is also appointed by the Probate Court to supervise the financial affairs of an individual found to be incapable of managing his/her own affairs to the extent that property is jeopardized unless management is provided. PCA Waiver participants are able to select qualified providers for services provision. In some circumstances, this may be a non-legally liable relative, who is not related to the consumers Conservator of Person or Conservator of Estate. Family members must meet the same qualifications as unrelated providers. Any reported concerns regarding fraudulent billing are addressed as it would be with other service vendors(e.g., investigation, provider termination, etc.) Adult Family Living/Foster Care agency vendors are paid and must maintain records of service provision.</textarea></span> </div> </div> <div class="checkboxGroup"><label><input id="svapdxC2_3:svcPolRelType:2" type="radio" name="svapdxC2_3:svcPolRelType" value="2" onclick="return callSave(this, event);" disabled="disabled" />&#160;Relatives/legal guardians may be paid for providing waiver services whenever the relative/legal guardian is qualified to provide services as specified in Appendix C-1/C-3.</label></div> <div class="firstIndent"> <p class="outputTextNB"> <label id="svapdxC2_3:lbl_svcPolRelQualCntl" for="svapdxC2_3:svcPolRelQualCntl" class="outputLabel"> <span id="svapdxC2_3:lbl_txt_svcPolRelQualCntl" class="outputTextNB">Specify the controls that are employed to ensure that payments are made only for services rendered.</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxC2_3:svcPolRelQualCntlChrCntLbl" for="svapdxC2_3:svcPolRelQualCntlChrCnt" class="outputLabel"> <span id="svapdxC2_3:svcPolRelQualCntlChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxC2_3:svcPolRelQualCntlChrCnt" type="text" name="svapdxC2_3:svcPolRelQualCntlChrCnt" class="chrCnt" size="6" /><span id="svapdxC2_3:svcPolRelQualCntlChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxC2_3:panel_svcPolRelQualCntl"><textarea id="svapdxC2_3:svcPolRelQualCntl" name="svapdxC2_3:svcPolRelQualCntl" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="checkboxGroup"><label><input id="svapdxC2_3:svcPolRelType:3" type="radio" name="svapdxC2_3:svcPolRelType" value="3" onclick="return callSave(this, event);" disabled="disabled" />&#160;Other policy.</label></div> <div class="firstIndent"> <p class="outputTextNB"> <label id="svapdxC2_3:lbl_svcPolRelOthDscr" for="svapdxC2_3:svcPolRelOthDscr" class="outputLabel"> <span id="svapdxC2_3:lbl_txt_svcPolRelOthDscr" class="outputTextNB">Specify:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxC2_3:svcPolRelOthDscrChrCntLbl" for="svapdxC2_3:svcPolRelOthDscrChrCnt" class="outputLabel"> <span id="svapdxC2_3:svcPolRelOthDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxC2_3:svcPolRelOthDscrChrCnt" type="text" name="svapdxC2_3:svcPolRelOthDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxC2_3:svcPolRelOthDscrChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxC2_3:panel_svcPolRelOthDscr"><textarea id="svapdxC2_3:svcPolRelOthDscr" name="svapdxC2_3:svcPolRelOthDscr" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="noShow"><label><input id="svapdxC2_3:svcPolRelType:4" type="radio" name="svapdxC2_3:svcPolRelType" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </LI> <LI> <p class="outputTextNB"> <strong>Open Enrollment of Providers.</strong> <label id="svapdxC2_3:lbl_svcPvdrEnrl" for="svapdxC2_3:svcPvdrEnrl" class="outputLabel"> <span id="svapdxC2_3:lbl_txt_svcPvdrEnrl" class="outputTextNB">Specify the processes that are employed to assure that all willing and qualified providers have the opportunity to enroll as waiver service providers as provided in 42 CFR &sect;431.51:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxC2_3:svcPvdrEnrlChrCntLbl" for="svapdxC2_3:svcPvdrEnrlChrCnt" class="outputLabel"> <span id="svapdxC2_3:svcPvdrEnrlChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxC2_3:svcPvdrEnrlChrCnt" type="text" name="svapdxC2_3:svcPvdrEnrlChrCnt" class="chrCnt" size="6" /><span id="svapdxC2_3:svcPvdrEnrlChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxC2_3:panel_svcPvdrEnrl"><textarea id="svapdxC2_3:svcPvdrEnrl" name="svapdxC2_3:svcPvdrEnrl" class="inputTextarea" onkeyup="Count(this);" readonly="readonly">The Connecticut Department of Social Services contracts with a fiscal intermediary to conduct outreach activities in order to increase awareness of the PCA Waiver Program within the community and to recruit qualified providers to serve the PCA populations. Outreach activities include: 1. Identifying those areas of the state in which service deficits exist; 2. Tailoring outreach approaches to best recruit the types of providers most needed to serve the PCA population on a regional and statewide basis; 3. Conducting at least one outreach session every twelve months in each of the Department's three regions during the contract period; 4. Conducting at least one community service provider outreach session each quarter during the contract period; 5. Utilizing appropriate methods to publicize outreach activities including, but not limited to, newsletters, individual contacts, direct mailings, print or other media advertisements, or other methods of communication as appropriate to each activity; and 6. Maintaining a direcory of potential providers who attend each activity or who are contacted through the outreach effort, including the date and place of each activity, the number of individuals who attend or are contacted, the number of individuals who subsequently participate in training, and the number of individuals, by specialty type,subsequently enrolled as Qualified Providers.</textarea></span> </div> </LI> </OL> <H2 id="pageTitle">Appendix C: Participant Services</H2> <H3 id="pageSubTitle">Quality Improvement: Qualified Providers</H3> <div class="paragraph"> <span class="outputTextNB em"> As a distinct component of the State’s quality improvement strategy, provide information in the following fields to detail the State’s methods for discovery and remediation. </span> </div> <ol class="alphaLC" id="CQa" start="1" > <li style="margin-top: 1em;"> <div class="paragraph"> <span class="outputText">Methods for Discovery: Qualified Providers</span> <p class="pph"> <span class="outputText em">The state demonstrates that it has designed and implemented an adequate system for assuring that all waiver services are provided by qualified providers.</span> </p> </div> <ol class="romanLC" id="CQai" start="1"> <li> <!-- a.i. --> <div>Sub-Assurances:</div> <ol class="alphaLC" start="1"> <li style="padding-bottom: 1em;"> <!-- a.i.a --> <div> <p> <span id="svapdxCQ_1:aiaSA" class="outputText em">Sub-Assurance: The State verifies that providers initially and continually meet required licensure and/or certification standards and adhere to other standards prior to their furnishing waiver services.</span> </p> <p class="pph"> <span class="outputText">Performance Measures</span> </p> <p class="pph"> <span class="outputTextNB em">For each performance measure the State will use to assess compliance with the statutory assurance, complete the following. Where possible, include numerator/denominator.</span> </p> <p class="pph"> <span class="outputTextNB em ul">For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.</span> </p> </div> <div class=""> <table id="svapdxCQ_1:dtPMPrntQPa" class="nstTableX" summary="Expanded dynamic table for Performance Measures" ><tbody > <tr ><td > <div style="padding-bottom: 1.5em; width:90%;" > <span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:pmName" class="inputTextPct">The number and percent of providers who meet licensure or certification standards prior to furnishing waiver services. The numerator is the number of qualified/credentialed providers and the denominator is the total number of providers</span> </div> </div> <table id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource" style="width: 90%" class="nstTableX" border="0" cellpadding="2" cellspacing="0" summary="dynamic table for Performance Measure Data Sources" ><tbody > <tr ><td ><label id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Other</span><div id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct">Provider enrollment logs</span></div></div></div><table id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:pmPnlGrdChkboxSet" class="nstTableX" border="1" cellpadding="3" cellspacing="0" style="vertical-align: top; margin-bottom: 1.5em;"> <tbody> <tr> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsRpSma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsSaPct" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaLtPct" class="outputText">Less than 100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsFdQu" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="inputTextarea" readonly="readonly">fiscal intermediary</textarea></span></div></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsFdCo" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsSaOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:dtDataSource:0:dssa6"></span></td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <div style="padding: 1em 0 1em 0;"> </div> <div> <span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:pmDAA" class="outputText" style="margin-top: 1.5em;">Data Aggregation and Analysis:</span> </div> <table id="pmPnlGrdChkboxSet" class="nstTableX" id="pmPnlGrdChkboxSet"cellpadding="3" cellspacing="0" border="1" style="vertical-align: top; width: 85%;"> <THEAD><tr align="left" valign="top"> <th id="rp" class="third"> <span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:txtPMfom2" class="outputTextNB em">(check each that applies):</span> </th> </tr></THEAD> <TBODY valign="top" align="left"> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:pmDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:pmDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:pmDaFdQu" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:pmDaRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:pmDaRpOthDsc" name="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:pmDaRpOthDsc" class="inputTextarea" readonly="readonly">fiscal intermediary</textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:pmDaFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:txtlbl_pmDaFdAn" class="outputText">Annually</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:pmDaFdCo" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:txtlblpmDaFdCo" class="outputText">Continuously and Ongoing</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup" > <input id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:pmDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:pmDaFdOtDsc" name="svapdxCQ_1:dtPMPrntQPa:0:svQmPerfMeas:pmDaFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> </tr> </TBODY> </table> <div> </div> </td> </tr> </tbody> </table> </div> </li> <li style="padding-bottom: 1em;"> <!-- a.i.b --> <div> <p> <span id="svapdxCQ_1:aibSA" class="outputText em">Sub-Assurance: The State monitors non-licensed/non-certified providers to assure adherence to waiver requirements.</span> </p> <p class="pph"> <span class="outputTextNB em">For each performance measure the State will use to assess compliance with the statutory assurance, complete the following. Where possible, include numerator/denominator.</span> </p> <p class="pph"> <span class="outputTextNB em ul">For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.</span> </p> </div> <div class=""> <table id="svapdxCQ_1:dtPMPrntQPb" class="nstTableX" summary="Expanded dynamic table for Performance Measures" ><tbody > <tr ><td > <div style="padding-bottom: 1.5em; width:90%;" > <span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:pmName" class="inputTextPct">Number and percent of non licensed/non certified provider applicants, by provider type who meet initial waiver qualifications.</span> </div> </div> <table id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource" style="width: 90%" class="nstTableX" border="0" cellpadding="2" cellspacing="0" summary="dynamic table for Performance Measure Data Sources" ><tbody > <tr ><td ><label id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Reports to State Medicaid Agency on delegated Administrative functions</span><div id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct"></span></div></div></div><table id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:pmPnlGrdChkboxSet" class="nstTableX" border="1" cellpadding="3" cellspacing="0" style="vertical-align: top; margin-bottom: 1.5em;"> <tbody> <tr> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsRpSma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsSaPct" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaLtPct" class="outputText">Less than 100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsFdQu" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="inputTextarea" readonly="readonly">Fiscal intermediary</textarea></span></div></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsFdCo" checked="checked" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsSaOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:dtDataSource:0:dssa6"></span></td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <div style="padding: 1em 0 1em 0;"> </div> <div> <span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:pmDAA" class="outputText" style="margin-top: 1.5em;">Data Aggregation and Analysis:</span> </div> <table id="pmPnlGrdChkboxSet" class="nstTableX" id="pmPnlGrdChkboxSet"cellpadding="3" cellspacing="0" border="1" style="vertical-align: top; width: 85%;"> <THEAD><tr align="left" valign="top"> <th id="rp" class="third"> <span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:txtPMfom2" class="outputTextNB em">(check each that applies):</span> </th> </tr></THEAD> <TBODY valign="top" align="left"> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:pmDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:pmDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:pmDaFdQu" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:pmDaRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:pmDaRpOthDsc" name="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:pmDaRpOthDsc" class="inputTextarea" readonly="readonly">Fiscal intermediary</textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:pmDaFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:txtlbl_pmDaFdAn" class="outputText">Annually</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:pmDaFdCo" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:txtlblpmDaFdCo" class="outputText">Continuously and Ongoing</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup" > <input id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:pmDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:pmDaFdOtDsc" name="svapdxCQ_1:dtPMPrntQPb:0:svQmPerfMeas:pmDaFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> </tr> </TBODY> </table> <div> </div> </td> </tr> <tr ><td > <div style="padding-bottom: 1.5em; width:90%;" > <span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:pmName" class="inputTextPct">Number and percent of non licensed/non certified provider applicants, by provider type who continually meet waiver qualifications.</span> </div> </div> <table id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource" style="width: 90%" class="nstTableX" border="0" cellpadding="2" cellspacing="0" summary="dynamic table for Performance Measure Data Sources" ><tbody > <tr ><td ><label id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Reports to State Medicaid Agency on delegated Administrative functions</span><div id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct"></span></div></div></div><table id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:pmPnlGrdChkboxSet" class="nstTableX" border="1" cellpadding="3" cellspacing="0" style="vertical-align: top; margin-bottom: 1.5em;"> <tbody> <tr> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsRpSma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsSaPct" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsFdMo" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaLtPct" class="outputText">Less than 100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="inputTextarea" readonly="readonly">Fiscal intermediary</textarea></span></div></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsFdCo" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsSaOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:dtDataSource:0:dssa6"></span></td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <div style="padding: 1em 0 1em 0;"> </div> <div> <span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:pmDAA" class="outputText" style="margin-top: 1.5em;">Data Aggregation and Analysis:</span> </div> <table id="pmPnlGrdChkboxSet" class="nstTableX" id="pmPnlGrdChkboxSet"cellpadding="3" cellspacing="0" border="1" style="vertical-align: top; width: 85%;"> <THEAD><tr align="left" valign="top"> <th id="rp" class="third"> <span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:txtPMfom2" class="outputTextNB em">(check each that applies):</span> </th> </tr></THEAD> <TBODY valign="top" align="left"> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:pmDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:pmDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:pmDaFdQu" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:pmDaRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:pmDaRpOthDsc" name="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:pmDaRpOthDsc" class="inputTextarea" readonly="readonly">Fiscal intermediary</textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:pmDaFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:txtlbl_pmDaFdAn" class="outputText">Annually</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:pmDaFdCo" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:txtlblpmDaFdCo" class="outputText">Continuously and Ongoing</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup" > <input id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:pmDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:pmDaFdOtDsc" name="svapdxCQ_1:dtPMPrntQPb:1:svQmPerfMeas:pmDaFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> </tr> </TBODY> </table> <div> </div> </td> </tr> </tbody> </table> </div> </li> <li style="padding-bottom: 1em;"> <!-- a.i.c --> <div> <p> <span id="svapdxCQ_1:aicSA" class="outputText em">Sub-Assurance: The State implements its policies and procedures for verifying that provider training is conducted in accordance with state requirements and the approved waiver.</span> </p> <p class="pph"> <span class="outputTextNB em">For each performance measure the State will use to assess compliance with the statutory assurance, complete the following. Where possible, include numerator/denominator.</span> </p> <p class="pph"> <span class="outputTextNB em ul">For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.</span> </p> </div> <div class=""> <table id="svapdxCQ_1:dtPMPrntQPC" class="nstTableX" summary="Expanded dynamic table for Performance Measures" ><tbody > <tr ><td > <div style="padding-bottom: 1.5em; width:90%;" > <span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:pmName" class="inputTextPct">The number and percent of employers who received contractually required training from the fiscal intermediary. The numerator is the number of employers who received training and the denominator is the number of employers</span> </div> </div> <table id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource" style="width: 90%" class="nstTableX" border="0" cellpadding="2" cellspacing="0" summary="dynamic table for Performance Measure Data Sources" ><tbody > <tr ><td ><label id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Training verification records</span><div id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct"></span></div></div></div><table id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:pmPnlGrdChkboxSet" class="nstTableX" border="1" cellpadding="3" cellspacing="0" style="vertical-align: top; margin-bottom: 1.5em;"> <tbody> <tr> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsRpSma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsSaPct" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaLtPct" class="outputText">Less than 100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsFdQu" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="inputTextarea" readonly="readonly">fiscal intermediary</textarea></span></div></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsFdCo" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsSaOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:dtDataSource:0:dssa6"></span></td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <div style="padding: 1em 0 1em 0;"> </div> <div> <span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:pmDAA" class="outputText" style="margin-top: 1.5em;">Data Aggregation and Analysis:</span> </div> <table id="pmPnlGrdChkboxSet" class="nstTableX" id="pmPnlGrdChkboxSet"cellpadding="3" cellspacing="0" border="1" style="vertical-align: top; width: 85%;"> <THEAD><tr align="left" valign="top"> <th id="rp" class="third"> <span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:txtPMfom2" class="outputTextNB em">(check each that applies):</span> </th> </tr></THEAD> <TBODY valign="top" align="left"> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:pmDaRpSma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:pmDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:pmDaFdQu" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:pmDaRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:pmDaRpOthDsc" name="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:pmDaRpOthDsc" class="inputTextarea" readonly="readonly">fiscal intermediary</textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:pmDaFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:txtlbl_pmDaFdAn" class="outputText">Annually</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:pmDaFdCo" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:txtlblpmDaFdCo" class="outputText">Continuously and Ongoing</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup" > <input id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:pmDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:pmDaFdOtDsc" name="svapdxCQ_1:dtPMPrntQPC:0:svQmPerfMeas:pmDaFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> </tr> </TBODY> </table> <div> </div> </td> </tr> </tbody> </table> </div> </li> </ol> </li> <li style="padding-top: 1.5em;"> <!-- a.ii. --> <div class="paragraph"> <label id="svapdxCQ_1:lbl_qmQpDiscDesc" for="svapdxCQ_1:qmQpDiscDesc" class="outputLabel"> <span id="svapdxCQ_1:txt_lbl_qmQpDiscDesc" class="outputTextNB">If applicable, in the textbox below provide any necessary additional information on the strategies employed by the State to discover/identify problems/issues within the waiver program, including frequency and parties responsible.</span></label> </div> <div></div> <div class="chrCntDiv"> <label id="svapdxCQ_1:qmQpDiscDescChrCntLbl" for="svapdxCQ_1:qmQpDiscDescChrCnt" class="outputLabel"> <span id="svapdxCQ_1:qmQpDiscDescChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxCQ_1:qmQpDiscDescChrCnt" type="text" name="svapdxCQ_1:qmQpDiscDescChrCnt" class="chrCnt" size="6" /><span id="svapdxCQ_1:qmQpDiscDescChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxCQ_1:panel_qmQpDiscDesc"><textarea id="svapdxCQ_1:qmQpDiscDesc" name="svapdxCQ_1:qmQpDiscDesc" class="inputTextarea" onkeyup="Count(this);" readonly="readonly">The fiscal intermediary provides quarterly documentation of outreach activities to recruit providers and the result of the outreach efforts. Additionally, the fiscal intermediary has a Program Compliance Supervisor who investigates potential fraud claims and provides the Department with a written summary and report of all claims.</textarea></span> </div> </li> </ol> </li> <li style="margin-top: 1em;"> <!-- b. --> <div class="paragraph"> <span class="outputText">Methods for Remediation/Fixing Individual Problems</span> </div> <ol class="romanLC" id="AQb" start="1"> <li> <!-- b.i. --> <div class="paragraph"> <label id="svapdxCQ_1:lbl_qmQpRemDesc" for="svapdxCQ_1:qmQpRemDesc" class="outputLabel"> <span id="svapdxCQ_1:txt_lbl_qmQpRemDesc" class="outputTextNB">Describe the State’s method for addressing individual problems as they are discovered. Include information regarding responsible parties and GENERAL methods for problem correction. In addition, provide information on the methods used by the State to document these items. </span></label> </div> <div></div> <div class="chrCntDiv"> <label id="svapdxCQ_1:qmQpRemDescChrCntLbl" for="svapdxCQ_1:qmQpRemDescChrCnt" class="outputLabel"> <span id="svapdxCQ_1:qmQpRemDescChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxCQ_1:qmQpRemDescChrCnt" type="text" name="svapdxCQ_1:qmQpRemDescChrCnt" class="chrCnt" size="6" /><span id="svapdxCQ_1:qmQpRemDescChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxCQ_1:panel_qmQpRemDesc"><textarea id="svapdxCQ_1:qmQpRemDesc" name="svapdxCQ_1:qmQpRemDesc" class="inputTextarea" onkeyup="Count(this);" readonly="readonly">An assigned CO staff member serves as the quality assurance officer for the PCA Waiver program. This staff member has daily contact with the fiscal intermediary for the purpose of resolving any discrepancies or issues related to contract compliance. For example, if a consumer calls with a complaint that they were not trained on the managing of their PCAs, the consumer would be in contact with the fiscal intermediary to resolve the complaint. If the Social Work staff believes a report to be potential fraud, it is referred to a Program Manager who decides if it should be referred to the Fraud and Recoveries Unit. Any correspondence done in written form is retained for future reference.</textarea></span> </div> </li> <li> <!-- b.ii. --> <div class="paragraph"> <span id="svapdxCQ_1:txt1">Remediation Data Aggregation</span> </div> <div> <span id="svapdxCQ_1:txt2">Remediation-related Data Aggregation and Analysis (including trend identification)</span> <table cellpadding="3" cellspacing="0" border="1" class="nstTableX" style="width:88%"> <thead align="left"> <tr> <th id="rp" style="width:44%;"> <span id="svapdxCQ_1:txtrp">Responsible Party</span><span id="svapdxCQ_1:txtrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" style="width:44%;"> <span id="svapdxCQ_1:txtfom">Frequency of data aggregation and analysis</span><span id="svapdxCQ_1:txtfom2" class="outputTextNB em">(check each that applies):</span> </th> </tr> </thead> <tbody align="left" valign="top"> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxCQ_1:qmQpDaRpSma" type="checkbox" name="svapdxCQ_1:qmQpDaRpSma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:lbl_qmQpDaRpSma" for="svapdxCQ_1:qmQpDaRpSma" class="outputLabel"> <span id="svapdxCQ_1:txtlbl_qmQpDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxCQ_1:qmQpDaFdWk" type="checkbox" name="svapdxCQ_1:qmQpDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:lbl_qmQpDaFdWk" for="svapdxCQ_1:qmQpDaFdWk" class="outputLabel"> <span id="svapdxCQ_1:txtlbl_qmQpDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxCQ_1:qmQpDaRpOpa" type="checkbox" name="svapdxCQ_1:qmQpDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:lbl_qmQpDaRpOpa" for="svapdxCQ_1:qmQpDaRpOpa" class="outputLabel"> <span id="svapdxCQ_1:txtlbl_qmQpDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxCQ_1:qmQpDaFdMo" type="checkbox" name="svapdxCQ_1:qmQpDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:lbl_qmQpDaFdMo" for="svapdxCQ_1:qmQpDaFdMo" class="outputLabel"> <span id="svapdxCQ_1:txtlbl_qmQpDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxCQ_1:qmQpDaRpCma" type="checkbox" name="svapdxCQ_1:qmQpDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:lbl_qmQpDaRpCma" for="svapdxCQ_1:qmQpDaRpCma" class="outputLabel"> <span id="svapdxCQ_1:txtlbl_qmQpDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxCQ_1:qmQpDaFdQu" type="checkbox" name="svapdxCQ_1:qmQpDaFdQu" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:lbl_qmQpDaFdQu" for="svapdxCQ_1:qmQpDaFdQu" class="outputLabel"> <span id="svapdxCQ_1:txtlbl_qmQpDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxCQ_1:qmQpDaRpOth" type="checkbox" name="svapdxCQ_1:qmQpDaRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:lbl_qmQpDaRpOth" for="svapdxCQ_1:qmQpDaRpOth" class="outputLabel"> <span id="svapdxCQ_1:txtlbl_qmQpDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxCQ_1:lbl2_qmQpDaRpOthDsc" for="svapdxCQ_1:qmQpDaRpOthDsc" class="outputLabel"> <span id="svapdxCQ_1:txtlbl2_qmQpDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxCQ_1:panel_qmQpDaRpOthDsc"><textarea id="svapdxCQ_1:qmQpDaRpOthDsc" name="svapdxCQ_1:qmQpDaRpOthDsc" class="inputTextarea" readonly="readonly">fiscal intermediary</textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxCQ_1:qmQpDaFdAn" type="checkbox" name="svapdxCQ_1:qmQpDaFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:lbl_qmQpDaFdAn" for="svapdxCQ_1:qmQpDaFdAn" class="outputLabel"> <span id="svapdxCQ_1:txtlbl_qmQpDaFdAn" class="outputText">Annually</span></label> </div> </td> </tr> <tr> <td headers="rp"> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxCQ_1:qmQpDaFdCo" type="checkbox" name="svapdxCQ_1:qmQpDaFdCo" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxCQ_1:lbl_qmQpDaFdCo" for="svapdxCQ_1:qmQpDaFdCo" class="outputLabel"> <span id="svapdxCQ_1:txtlblqmQpDaFdCo" class="outputText">Continuously and Ongoing</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxCQ_1:qmQpDaFdOt" type="checkbox" name="svapdxCQ_1:qmQpDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxCQ_1:lbl_qmQpDaFdOt" for="svapdxCQ_1:qmQpDaFdOt" class="outputLabel"> <span id="svapdxCQ_1:txtlblqmQpDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxCQ_1:lbl2_qmQpDaFdOtDsc" for="svapdxCQ_1:qmQpDaFdOtDsc" class="outputLabel"> <span id="svapdxCQ_1:txtlbl2qmQpDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxCQ_1:panel_qmQpDaFdOtDsc"><textarea id="svapdxCQ_1:qmQpDaFdOtDsc" name="svapdxCQ_1:qmQpDaFdOtDsc" class="inputTextarea" readonly="readonly"></textarea></span> </div> </div> </td> </tr> </tbody> </table> </div> </li> </ol> </li> <li style="margin-top: 1em;"> <!-- c. --> <div> <span class="outputText">Timelines</span> </div> <div> <label id="svapdxCQ_1:lbl_qmQpTimeLn" for="svapdxCQ_1:qmQpTimeLn" class="outputLabel"> <span id="svapdxCQ_1:txt_lbl_qmQpTimeLn" class="outputTextNB">When the State does not have all elements of the Quality Improvement Strategy in place, provide timelines to design methods for discovery and remediation related to the assurance of Qualified Providers that are currently non-operational.</span></label> <div> <div class="checkboxGroup"><label><input id="svapdxCQ_1:qmQpTimeLn:1" type="radio" name="svapdxCQ_1:qmQpTimeLn" checked="checked" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;No</label></div> <div class="checkboxGroup"><label><input id="svapdxCQ_1:qmQpTimeLn:0" type="radio" name="svapdxCQ_1:qmQpTimeLn" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;Yes</label></div> <div class="noShow"><label><input id="svapdxCQ_1:qmQpTimeLn:2" type="radio" name="svapdxCQ_1:qmQpTimeLn" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </div> </div> <div class="firstIndent"> <label id="svapdxCQ_1:lbl_qmQpTimeLnDsc" for="svapdxCQ_1:qmQpTimeLnDsc" class="outputLabel"> <span id="svapdxCQ_1:txt_lbl_qmQpTimeLnDsc" class="outputTextNB">Please provide a detailed strategy for assuring Qualified Providers, the specific timeline for implementing identified strategies, and the parties responsible for its operation.</span></label> <div></div> <div class="chrCntDiv"> <label id="svapdxCQ_1:qmQpTimeLnDscChrCntLbl" for="svapdxCQ_1:qmQpTimeLnDscChrCnt" class="outputLabel"> <span id="svapdxCQ_1:qmQpTimeLnDscChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxCQ_1:qmQpTimeLnDscChrCnt" type="text" name="svapdxCQ_1:qmQpTimeLnDscChrCnt" class="chrCnt" size="6" /><span id="svapdxCQ_1:qmQpTimeLnDscChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxCQ_1:panel_qualc"><textarea id="svapdxCQ_1:qmQpTimeLnDsc" name="svapdxCQ_1:qmQpTimeLnDsc" class="inputTextarea" readonly="readonly"></textarea></span> </div> </div> </li> </ol> <H2 id="pageTitle">Appendix C: Participant Services</H2> <H3 id="pageSubTitle">C-3: Waiver Services Specifications <SPAN id="pageNumber"></SPAN></H3> <p class="outputTextNB"> Section C-3 'Service Specifications' is incorporated into Section C-1 'Waiver Services.' </p> <H2 id="pageTitle">Appendix C: Participant Services</H2> <H3 id="pageSubTitle">C-4: Additional Limits on Amount of Waiver Services <SPAN id="pageNumber"></SPAN></H3> <OL class="alphaLC" start="1"> <LI> <p class="outputTextNB"> <strong>Additional Limits on Amount of Waiver Services.</strong> Indicate whether the waiver employs any of the following additional limits on the amount of waiver services (<em>select one</em>). </p> <div class="noShow"><label><input id="svapdxC4_1:svcAdlLim:2" type="radio" name="svapdxC4_1:svcAdlLim" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> <div class="checkboxGroup"> <label><input id="svapdxC4_1:svcAdlLim:1" type="radio" name="svapdxC4_1:svcAdlLim" checked="checked" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;Not applicable</label><span id="svapdxC4_1:txt_lbl_svcAdlLim1" class="outputTextNB">- The State does not impose a limit on the amount of waiver services except as provided in Appendix C-3.</span> </div> <div class="checkboxGroup"> <label><input id="svapdxC4_1:svcAdlLim:0" type="radio" name="svapdxC4_1:svcAdlLim" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;Applicable</label><span id="svapdxC4_1:txt_lbl_svcAdlLim0" class="outputTextNB"> - The State imposes additional limits on the amount of waiver services.</span> </div> <div class="firstIndent"> <p class="outputTextNB"> When a limit is employed, specify: (a) the waiver services to which the limit applies; (b) the basis of the limit, including its basis in historical expenditure/utilization patterns and, as applicable, the processes and methodologies that are used to determine the amount of the limit to which a participant's services are subject; (c) how the limit will be adjusted over the course of the waiver period; (d) provisions for adjusting or making exceptions to the limit based on participant health and welfare needs or other factors specified by the state; (e) the safeguards that are in effect when the amount of the limit is insufficient to meet a participant's needs; (f) how participants are notified of the amount of the limit. (<em>check each that applies</em>) </p> <div class="checkboxGroup"> <input id="svapdxC4_1:svcLimSet" type="checkbox" name="svapdxC4_1:svcLimSet" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxC4_1:lbl_svcLimSet" for="svapdxC4_1:svcLimSet" class="outputLabel"> <span id="svapdxC4_1:lbl_txt_svcLimSet1" class="outputText">Limit(s) on Set(s) of Services.</span><span id="svapdxC4_1:lbl_txt_svcLimSet2" class="outputTextNB"> There is a limit on the maximum dollar amount of waiver services that is authorized for one or more sets of services offered under the waiver.</span></label> </div> <div class="firstIndent"> <label id="svapdxC4_1:lbl_svcLimSetDscr" for="svapdxC4_1:svcLimSetDscr" class="outputLabel"> <span id="svapdxC4_1:lbl_txt_svcLimSetDscr" class="outputTextNB em">Furnish the information specified above.</span></label> <p></p> <div class="chrCntDiv"> <label id="svapdxC4_1:svcLimSetDscrChrCntLbl" for="svapdxC4_1:svcLimSetDscrChrCnt" class="outputLabel"> <span id="svapdxC4_1:svcLimSetDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxC4_1:svcLimSetDscrChrCnt" type="text" name="svapdxC4_1:svcLimSetDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxC4_1:svcLimSetDscrChrCntMax" class="chrCnt"> out of 24000</span> </div> <div class="inputTextareaWA"> <span id="svapdxC4_1:panel_svcLimSetDscr"><textarea id="svapdxC4_1:svcLimSetDscr" name="svapdxC4_1:svcLimSetDscr" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="checkboxGroup"> <input id="svapdxC4_1:svcIndvBdgt" type="checkbox" name="svapdxC4_1:svcIndvBdgt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxC4_1:lbl_svcIndvBdgt" for="svapdxC4_1:svcIndvBdgt" class="outputLabel"> <span id="svapdxC4_1:lbl_txt_svcIndvBdgt1" class="outputText">Prospective Individual Budget Amount.</span><span id="svapdxC4_1:lbl_txt_svcIndvBdgt2" class="outputTextNB"> There is a limit on the maximum dollar amount of waiver services authorized for each specific participant.</span></label> </div> <div class="firstIndent"> <label id="svapdxC4_1:lbl_svcIndvBdgtDscr" for="svapdxC4_1:svcIndvBdgtDscr" class="outputLabel"> <span id="svapdxC4_1:lbl_txt_svcIndvBdgtDscr" class="outputTextNB em">Furnish the information specified above.</span></label> <p></p> <div class="chrCntDiv"> <label id="svapdxC4_1:svcIndvBdgtDscrChrCntLbl" for="svapdxC4_1:svcIndvBdgtDscrChrCnt" class="outputLabel"> <span id="svapdxC4_1:svcIndvBdgtDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxC4_1:svcIndvBdgtDscrChrCnt" type="text" name="svapdxC4_1:svcIndvBdgtDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxC4_1:svcIndvBdgtDscrChrCntMax" class="chrCnt"> out of 24000</span> </div> <div class="inputTextareaWA"> <span id="svapdxC4_1:panel_svcIndvBdgtDscr"><textarea id="svapdxC4_1:svcIndvBdgtDscr" name="svapdxC4_1:svcIndvBdgtDscr" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="checkboxGroup"> <input id="svapdxC4_1:svcBdgtLos" type="checkbox" name="svapdxC4_1:svcBdgtLos" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxC4_1:lbl_svcBdgtLos" for="svapdxC4_1:svcBdgtLos" class="outputLabel"> <span id="svapdxC4_1:lbl_txt_svcBdgtLos1" class="outputText">Budget Limits by Level of Support.</span><span id="svapdxC4_1:lbl_txt_svcBdgtLos2" class="outputTextNB"> Based on an assessment process and/or other factors, participants are assigned to funding levels that are limits on the maximum dollar amount of waiver services.</span></label> </div> <div class="firstIndent"> <label id="svapdxC4_1:lbl_svcBdgtLosDscr" for="svapdxC4_1:svcBdgtLosDscr" class="outputLabel"> <span id="svapdxC4_1:lbl_txt_svcBdgtLosDscr" class="outputTextNB em">Furnish the information specified above.</span></label> <p></p> <div class="chrCntDiv"> <label id="svapdxC4_1:svcBdgtLosDscrChrCntLbl" for="svapdxC4_1:svcBdgtLosDscrChrCnt" class="outputLabel"> <span id="svapdxC4_1:svcBdgtLosDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxC4_1:svcBdgtLosDscrChrCnt" type="text" name="svapdxC4_1:svcBdgtLosDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxC4_1:svcBdgtLosDscrChrCntMax" class="chrCnt"> out of 24000</span> </div> <div class="inputTextareaWA"> <span id="svapdxC4_1:panel_svcBdgtLosDscr"><textarea id="svapdxC4_1:svcBdgtLosDscr" name="svapdxC4_1:svcBdgtLosDscr" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="checkboxGroup"> <input id="svapdxC4_1:svcLimOth" type="checkbox" name="svapdxC4_1:svcLimOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxC4_1:lbl_svcLimOth" for="svapdxC4_1:svcLimOth" class="outputLabel"> <span id="svapdxC4_1:lbl_txt_svcLimOth1" class="outputText">Other Type of Limit.</span><span id="svapdxC4_1:lbl_txt_svcLimOth2" class="outputTextNB"> The State employs another type of limit.</span></label> </div> <div class="firstIndent"> <label id="svapdxC4_1:lbl_svcLimOthDscr" for="svapdxC4_1:svcLimOthDscr" class="outputLabel"> <span id="svapdxC4_1:lbl_txt_svcLimOthDscr" class="outputTextNB em">Describe the limit and furnish the information specified above.</span></label> <p></p> <div class="chrCntDiv"> <label id="svapdxC4_1:svcLimOthDscrChrCntLbl" for="svapdxC4_1:svcLimOthDscrChrCnt" class="outputLabel"> <span id="svapdxC4_1:svcLimOthDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxC4_1:svcLimOthDscrChrCnt" type="text" name="svapdxC4_1:svcLimOthDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxC4_1:svcLimOthDscrChrCntMax" class="chrCnt"> out of 24000</span> </div> <div class="inputTextareaWA"> <span id="svapdxC4_1:panel_svcLimOthDscr"><textarea id="svapdxC4_1:svcLimOthDscr" name="svapdxC4_1:svcLimOthDscr" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="noShow"> <input id="svapdxC4_1:svcLimNa" type="checkbox" name="svapdxC4_1:svcLimNa" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxC4_1:lbl_svcLimNa" for="svapdxC4_1:svcLimNa" class="outputLabel"> <span id="svapdxC4_1:lbl_txt_svcLimNa1" class="outputText">Not applicable.</span><span id="svapdxC4_1:lbl_txt_svcLimNa2" class="outputTextNB"> The State does not impose a limit on the amount of waiver services except as provided in Appendix C-3.</span></label> </div> </div> </LI> </OL> <H2 id="pageTitle">Appendix C: Participant Services</H2> <H3 id="pageSubTitle">C-5: Home and Community-Based Settings <SPAN id="pageNumber"></SPAN></H3> <div class="outputTextNB"> <label id="svapdxC5_1:lbl_hcbSettings" for="svapdxC5_1:hcbSettings" class="outputLabel"> <span id="svapdxC5_1:txt_lbl_hcbSettings" class="outputTextNB">Explain how residential and non-residential settings in this waiver comply with federal HCB Settings requirements at 42 CFR 441.301(c)(4)-(5) and associated CMS guidance. Include:</span></label> <ol class="numeric"> <li> <p class="outputTextNB"> Description of the settings and how they meet federal HCB Settings requirements, at the time of submission and in the future. </p> </li> <li> <p class="outputTextNB"> Description of the means by which the state Medicaid agency ascertains that all waiver settings meet federal HCB Setting requirements, at the time of this submission and ongoing. </p> </li> </ol> </div> <div> <span class="outputTextNB em"> Note instructions at Module 1, Attachment #2, <u>HCB Settings Waiver Transition Plan</u> for description of settings that do not meet requirements at the time of submission. Do not duplicate that information here. </span> </div> <p></P> <div class="chrCntDiv"> <label id="svapdxC5_1:hcbSettingsChrCntLbl" for="svapdxC5_1:hcbSettingsChrCnt" class="outputLabel"> <span id="svapdxC5_1:hcbSettingsChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxC5_1:hcbSettingsChrCnt" type="text" name="svapdxC5_1:hcbSettingsChrCnt" class="chrCnt" size="6" /><span id="svapdxC5_1:hcbSettingsChrCntMax" class="chrCnt"> out of 60000</span> </div> <div class="inputTextareaWA"> <span id="svapdxC5_1:panel_hcbSettings"><textarea id="svapdxC5_1:hcbSettings" name="svapdxC5_1:hcbSettings" class="inputTextareaLong" onkeyup="Count(this);" readonly="readonly">See Main Module Attachment B</textarea></span> </div> <H2 id="pageTitle">Appendix D: Participant-Centered Planning and Service Delivery</H2> <H3 id="pageSubTitle">D-1: Service Plan Development <span id="pageNumber">(1 of 8)</span></H3> <div class="outputTextNB"> <label id="svapdxD1_1:lblprintPlnTitle" for="svapdxD1_1:printPlnTitle" class="outputLabel"> <span id="svapdxD1_1:lbltxt_printPlnTitle" class="outputText">State Participant-Centered Service Plan Title:</span></label><textarea id="svapdxD1_1:printPlnTitle" name="svapdxD1_1:printPlnTitle" class="inputTextarea" readonly="readonly">Personal Care Assistance Plan</textarea> </div> <OL class="alphaLC" start="1"> <LI> <div class="outputTextNB"> <strong>Responsibility for Service Plan Development.</strong> Per 42 CFR §441.301(b)(2), specify who is responsible for the development of the service plan and the qualifications of these individuals <em>(select each that applies):</em> </div> <div class="checkboxGroup"> <input id="svapdxD1_1:plnDevRspRN" type="checkbox" name="svapdxD1_1:plnDevRspRN" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxD1_1:lblplnDevRspRN" for="svapdxD1_1:plnDevRspRN" class="outputLabel"> <span id="svapdxD1_1:lbltxt_plnDevRspRN" class="outputText">Registered nurse, licensed to practice in the State</span></label> </div> <div class="checkboxGroup"> <input id="svapdxD1_1:plnDevRspLPN" type="checkbox" name="svapdxD1_1:plnDevRspLPN" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxD1_1:lblplnDevRspLPN" for="svapdxD1_1:plnDevRspLPN" class="outputLabel"> <span id="svapdxD1_1:lbltxt_plnDevRspLPN" class="outputText">Licensed practical or vocational nurse, acting within the scope of practice under State law</span></label> </div> <div class="checkboxGroup"> <input id="svapdxD1_1:plnDevRspPhys" type="checkbox" name="svapdxD1_1:plnDevRspPhys" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxD1_1:lblplnDevRspPhys" for="svapdxD1_1:plnDevRspPhys" class="outputLabel"> <span id="svapdxD1_1:text3" class="outputText">Licensed physician (M.D. or D.O)</span></label> </div> <div class="checkboxGroup"> <input id="svapdxD1_1:plnDevRspCsMgr" type="checkbox" name="svapdxD1_1:plnDevRspCsMgr" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxD1_1:lblplnDevRspCsMgr" for="svapdxD1_1:plnDevRspCsMgr" class="outputLabel"> <span id="svapdxD1_1:lbltxt_plnDevRspCsMgr1" class="outputText">Case Manager</span><span id="svapdxD1_1:lbltxt_plnDevRspCsMgr2" class="outputTextNB"> (qualifications specified in Appendix C-1/C-3)</span></label> </div> <div class="checkboxGroup"> <input id="svapdxD1_1:plnDevRspCSMgrQual" type="checkbox" name="svapdxD1_1:plnDevRspCSMgrQual" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxD1_1:lblplnDevRspCSMgrQual" for="svapdxD1_1:plnDevRspCSMgrQual" class="outputLabel"> <span id="svapdxD1_1:lbltxt_plnDevRspCSMgrQual1" class="outputText">Case Manager</span><span id="svapdxD1_1:lbltxt_plnDevRspCSMgrQual2" class="outputTextNB"> (qualifications not specified in Appendix C-1/C-3).</span></label> </div> <div class="firstIndent"> <label id="svapdxD1_1:lbl_plnDevRspCSMgrQualDscr" for="svapdxD1_1:plnDevRspCSMgrQualDscr" class="outputLabel"> <span id="svapdxD1_1:lbl_txt_plnDevRspCSMgrQualDscr" class="outputTextNB em">Specify qualifications:</span></label> <p></p> <div class="chrCntDiv"> <label id="svapdxD1_1:plnDevRspCSMgrQualDscrChrCntLbl" for="svapdxD1_1:plnDevRspCSMgrQualDscrChrCnt" class="outputLabel"> <span id="svapdxD1_1:plnDevRspCSMgrQualDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxD1_1:plnDevRspCSMgrQualDscrChrCnt" type="text" name="svapdxD1_1:plnDevRspCSMgrQualDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxD1_1:plnDevRspCSMgrQualDscrChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxD1_1:panel_plnDevRspCSMgrQualDscr"><textarea id="svapdxD1_1:plnDevRspCSMgrQualDscr" name="svapdxD1_1:plnDevRspCSMgrQualDscr" class="inputTextarea15" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="checkboxGroup"> <input id="svapdxD1_1:plnDevRspSocWrk" type="checkbox" name="svapdxD1_1:plnDevRspSocWrk" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxD1_1:lblplnDevRspSocWrk" for="svapdxD1_1:plnDevRspSocWrk" class="outputLabel"> <span id="svapdxD1_1:text6" class="outputText">Social Worker</span></label> </div> <div class="firstIndent"> <label id="svapdxD1_1:lbl_plnDevRspSocWrkQualDscr" for="svapdxD1_1:plnDevRspSocWrkQualDscr" class="outputLabel"> <span id="svapdxD1_1:lbl_txt_plnDevRspSocWrkQualDscr" class="outputTextNB em">Specify qualifications:</span></label> <p></p> <div class="chrCntDiv"> <label id="svapdxD1_1:plnDevRspSocWrkQualDscrChrCntLbl" for="svapdxD1_1:plnDevRspSocWrkQualDscrChrCnt" class="outputLabel"> <span id="svapdxD1_1:plnDevRspSocWrkQualDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxD1_1:plnDevRspSocWrkQualDscrChrCnt" type="text" name="svapdxD1_1:plnDevRspSocWrkQualDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxD1_1:plnDevRspSocWrkQualDscrChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxD1_1:panel_plnDevRspSocWrkQualDscr"><textarea id="svapdxD1_1:plnDevRspSocWrkQualDscr" name="svapdxD1_1:plnDevRspSocWrkQualDscr" class="inputTextarea15" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="checkboxGroup"> <input id="svapdxD1_1:plnDevRspOthIndv" type="checkbox" name="svapdxD1_1:plnDevRspOthIndv" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxD1_1:lblplnDevRspOthIndv" for="svapdxD1_1:plnDevRspOthIndv" class="outputLabel"> <span id="svapdxD1_1:lbltxt_plnDevRspOthIndv" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxD1_1:lbl_plnDevRspOthIndvDscr" for="svapdxD1_1:plnDevRspOthIndvDscr" class="outputLabel"> <span id="svapdxD1_1:lbl_txt_plnDevRspOthIndvDscr" class="outputTextNB em">Specify the individuals and their qualifications:</span></label> <p></p> <div class="chrCntDiv"> <label id="svapdxD1_1:plnDevRspOthIndvDscrChrCntLbl" for="svapdxD1_1:plnDevRspOthIndvDscrChrCnt" class="outputLabel"> <span id="svapdxD1_1:plnDevRspOthIndvDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxD1_1:plnDevRspOthIndvDscrChrCnt" type="text" name="svapdxD1_1:plnDevRspOthIndvDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxD1_1:plnDevRspOthIndvDscrChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxD1_1:panel_plnDevRspOthIndvDscr"><textarea id="svapdxD1_1:plnDevRspOthIndvDscr" name="svapdxD1_1:plnDevRspOthIndvDscr" class="inputTextarea15" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> </LI> </OL> <H2 id="pageTitle">Appendix D: Participant-Centered Planning and Service Delivery</H2> <H3 id="pageSubTitle">D-1: Service Plan Development <span id="pageNumber">(2 of 8)</span></H3> <ol class="alphaLC" start="2"> <li> <div class="outputTextNB"> <strong>Service Plan Development Safeguards.</strong> <em>Select one:</em> <table id="svapdxD1_2:plnDevrOthSvcAllwd" class="selectOneRadio"> <tr> <td> <input type="radio" checked="checked" name="svapdxD1_2:plnDevrOthSvcAllwd" id="svapdxD1_2:plnDevrOthSvcAllwd:0" value="0" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxD1_2:plnDevrOthSvcAllwd:0"> Entities and/or individuals that have responsibility for service plan development may not provide other direct waiver services to the participant.</label></td> </tr> <tr> <td> <input type="radio" name="svapdxD1_2:plnDevrOthSvcAllwd" id="svapdxD1_2:plnDevrOthSvcAllwd:1" value="1" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxD1_2:plnDevrOthSvcAllwd:1"> Entities and/or individuals that have responsibility for service plan development may provide other direct waiver services to the participant.</label></td> </tr> </table> <div class="firstIndent"> <label id="svapdxD1_2:lbl_plnDevrOthSvcSfg" for="svapdxD1_2:plnDevrOthSvcSfg" class="outputLabel"> <span id="svapdxD1_2:lbltxt_plnDevrOthSvcSfg1" class="outputTextNB">The State has established the following safeguards to ensure that service plan development is conducted in the best interests of the participant.</span><span id="svapdxD1_2:lbltxt_plnDevrOthSvcSfg2" class="outputTextNB em"> Specify:</span></label> <p></p> <div class="chrCntDiv"> <label id="svapdxD1_2:plnDevrOthSvcSfgChrCntLbl" for="svapdxD1_2:plnDevrOthSvcSfgChrCnt" class="outputLabel"> <span id="svapdxD1_2:plnDevrOthSvcSfgChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxD1_2:plnDevrOthSvcSfgChrCnt" type="text" name="svapdxD1_2:plnDevrOthSvcSfgChrCnt" class="chrCnt" size="6" /><span id="svapdxD1_2:plnDevrOthSvcSfgChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxD1_2:panel_plnDevrOthSvcSfg"><textarea id="svapdxD1_2:plnDevrOthSvcSfg" name="svapdxD1_2:plnDevrOthSvcSfg" class="inputTextareaLong" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> </div> </li> </ol> <H2 id="pageTitle">Appendix D: Participant-Centered Planning and Service Delivery</H2> <H3 id="pageSubTitle">D-1: Service Plan Development <span id="pageNumber">(3 of 8)</span></H3> <ol class="alphaLC" start="3"> <li> <div class="outputTextNB"> <strong>Supporting the Participant in Service Plan Development.</strong> <label id="svapdxD1_3:lbl_plnPtcSpptDscr" for="svapdxD1_3:plnPtcSpptDscr" class="outputLabel"> <span id="svapdxD1_3:lbltxt_plnPtcSpptDscr" class="outputTextNB">Specify: (a) the supports and information that are made available to the participant (and/or family or legal representative, as appropriate) to direct and be actively engaged in the service plan development process and (b) the participant's authority to determine who is included in the process.</span></label> </div> <p></p> <div class="chrCntDiv"> <label id="svapdxD1_3:plnPtcSpptDscrChrCntLbl" for="svapdxD1_3:plnPtcSpptDscrChrCnt" class="outputLabel"> <span id="svapdxD1_3:plnPtcSpptDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxD1_3:plnPtcSpptDscrChrCnt" type="text" name="svapdxD1_3:plnPtcSpptDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxD1_3:plnPtcSpptDscrChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxD1_3:panel_plnPtcSpptDscr"><textarea id="svapdxD1_3:plnPtcSpptDscr" name="svapdxD1_3:plnPtcSpptDscr" class="inputTextareaLong" onkeyup="Count(this);" readonly="readonly">The Access Agency Care Managers are required to assist every PCA Waiver participant in developing a Person-Centered Service Plan. This individualized plan is written through a team process that includes the participant, his or her conservator as applicable, and other relevant persons as directed by the participant. The PCA Waiver brochure that outlines the program includes a section that addresses person-centered planning. The waiver participant, will be made aware of the availability of self directed PCA services available under the state plan as well as services to support them in their choice to self direct their services. The Person-Centered Planning process training covers issues such as client choice, networking, and team building.</textarea></span> </div> </li> </ol> <H2 id="pageTitle">Appendix D: Participant-Centered Planning and Service Delivery</H2> <H3 id="pageSubTitle">D-1: Service Plan Development <span id="pageNumber">(4 of 8)</span></H3> <ol class="alphaLC" start="4"> <li> <div class="outputTextNB"> <strong>Service Plan Development Process.</strong> <label id="svapdxD1_4:lbl_plnDevProc" for="svapdxD1_4:plnDevProc" class="outputLabel"> <span id="svapdxD1_4:lbltxt_plnDevProc" class="outputTextNB">In four pages or less, describe the process that is used to develop the participant-centered service plan, including: (a) who develops the plan, who participates in the process, and the timing of the plan; (b) the types of assessments that are conducted to support the service plan development process, including securing information about participant needs, preferences and goals, and health status; (c) how the participant is informed of the services that are available under the waiver; (d) how the plan development process ensures that the service plan addresses participant goals, needs (including health care needs), and preferences; (e) how waiver and other services are coordinated; (f) how the plan development process provides for the assignment of responsibilities to implement and monitor the plan; and, (g) how and when the plan is updated, including when the participant's needs change. State laws, regulations, and policies cited that affect the service plan development process are available to CMS upon request through the Medicaid agency or the operating agency (if applicable):</span></label> <p></p> </div> <div class="chrCntDiv"> <label id="svapdxD1_4:plnDevProcChrCntLbl" for="svapdxD1_4:plnDevProcChrCnt" class="outputLabel"> <span id="svapdxD1_4:plnDevProcChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxD1_4:plnDevProcChrCnt" type="text" name="svapdxD1_4:plnDevProcChrCnt" class="chrCnt" size="6" /><span id="svapdxD1_4:plnDevProcChrCntMax" class="chrCnt"> out of 24000</span> </div> <div class="inputTextareaWA"> <span id="svapdxD1_4:panel_plnDevProc"><textarea id="svapdxD1_4:plnDevProc" name="svapdxD1_4:plnDevProc" class="inputTextareaLong" onkeyup="Count(this);" readonly="readonly">To be eligible for PCA Waiver services, consumers must require hands on assistance with at least two ADLs. The care manager in consultation with the consumer and his/her representative develop the person centered service plan. A person-centered planning process is utilized and is driven by the participant. The individual also has the right to decide who should be included in the person-centered planning process. The process also provides all necessary information to support the individual to direct the process to the maximum extent possible. The process also occurs at a time and location convenient to the individual. The person-centered planning process also reflects cultural considerations and discusses strategies for addressing areas of disagreement. It also offers the participant choices regarding services and supports and who they receive them from. A plan of care based on the consumer's physical limitations governed by the number of ADL’s requiring hands on assistance. The plan needs to reflect what is important to the individual to ensure delivery of services in a manner reflecting personal preferences while ensuring health and welfare of the participant. The planning process identifies strengths, preferences, needs and desired outcomes for the participant. It also identifies person-centered goals and preferences related to all aspects of their life. The plan includes identified risks and plans to address the risks.The initial plan is submitted to the Alternate Care Unit for final approval. Initial care plans are developed using a standardized form. This form requires plan development informed by the following constellations of care: -Health -Life Planning -Behavioral/Cognitive Issues -Communication -Risk Indicators -Functional Assessment -Community-Based Supports -Environment The Cost of Care Plan is also calculated. This plan includes all services funded under Medicaid and outside sources including but not limted to PCA, nursing services, PT/OT, PERS, Adult Day Care and Home Delivered Meals. The initial Service Plan and the Cost of Care Plan are submitted to the Alternate Care Unit for final approval. Care Managers then discuss the plans with the client and/or their representative and any other person they want involved in the planning process and sign with the client an agreed upon plan that best meets the needs of the consumer. Additionally, after an initial plan is developed if the client and/or their representative feel an increase or decrease in service is needed, they will contact their care manager who will make a home visit and reassess the plan as needed. The PCA waiver program is person-centered, reflective of an approach to ensure that individual consumer presentations and needs are supported congruent with the eligible population standards. This service operates under ongoing oversight checks and balances built in through DSS staff monitoring, fiscal agent coordination and reporting, and service system documentation. All client specific actions are documented in the consumer's case record. The requirement for documented client choice regarding institutional versus community-based services is evidenced through consumer attestation and signature as part of the waiver application process. A process is also in place to ensure that consumers can affect individualized provider choice. Care managers share with waiver consumers the provider listing, which is developed by a DSS contracted fiduciary. Clients are afforded the opportunity to speak with and/or interview prospective providers prior to selection. The Participant selects personal care assistants, and is ultimately the employer of record for PCA’s and has responsibility for hiring, managing and firing his or her providers. The written service plan must: (i) Reflect that the setting chosen by the individual is integrated in, and supports full access of individuals receiving HCBS to the greater community, including opportunities to seek employment and work in competitive integrated settings, engage in community live, control personal resources, and receive services in the community to the same degree of access as individuals not receiving Medicaid HCBS. (ii) Reflect the individual&#8217;s strengths and preferences. (iii) Reflect clinical and support needs as identified through and assessment of functional need. (iv) Include individually identified goals and desired outcomes. (v) Reflect the services and supports (paid and unpaid) that will assist the individual to achieve identified goals, and the providers of those services and supports, including natural supports. (vi) Reflect risk factors and measures in place to minimize them, including individualized back-up plans and strategies when needed. (vii) Be understandable to the individual receiving services and supports, and the individuals important in supporting him or her. At a minimum, for the written plan to be understandable, it must be written in plain language and in a manner that is accessible to individuals with disabilities and persons who are limited English proficient, consistent with &sect;435.905(b) of this chapter. (viii) Identify the individual and/or entity responsible for monitoring the plan. (ix) Be finalized and agreed to, with the informed consent of the individual in writing, and signed by all individuals and providers responsible for its implementation. (x) Be distributed to the individual and other people involved in the plan. (xi) Include those services, the purpose or control of which the individual elects to self-direct. (xii) Prevent the provision of unnecessary or inappropriate services and supports. (xiii) Document any modification of the additional conditions, under paragraph (c)(4)(vi(A) through (D) of this section, must be supported by a specific assessed need and justified in the person-centered service plan. The following requirements must be documented in the person0centered service plan: a. Identify a specific and individualized assessed need. b. Document the positive interventions and supports used prior to any modifications to the person-centered service plan. c. Document less intrusive methods of meeting the need that have been tried but did not work. d. Include a clear description of the condition that is directly proportionate to the specific assessed need. e. Include a regular collection and review of data to measure the ongoing effectiveness of the modification. f. Include established time limits for periodic reviews to determine if the modification is still necessary or and be terminated. g. Include informed consent of the individual. h. Include and assurance that interventions and supports will cause no harm to the individual.</textarea></span> </div> </li> </ol> <H2 id="pageTitle">Appendix D: Participant-Centered Planning and Service Delivery</H2> <H3 id="pageSubTitle">D-1: Service Plan Development <span id="pageNumber">(5 of 8)</span></H3> <ol class="alphaLC" start="5"> <li> <div class="outputTextNB"> <strong>Risk Assessment and Mitigation.</strong> <label id="svapdxD1_5:lbl_plnRskAssMit" for="svapdxD1_5:plnRskAssMit" class="outputLabel"> <span id="svapdxD1_5:lbltxt_plnRskAssMit" class="outputTextNB">Specify how potential risks to the participant are assessed during the service plan development process and how strategies to mitigate risk are incorporated into the service plan, subject to participant needs and preferences. In addition, describe how the service plan development process addresses backup plans and the arrangements that are used for backup.</span></label> <p></p> </div> <div class="chrCntDiv"> <label id="svapdxD1_5:plnRskAssMitChrCntLbl" for="svapdxD1_5:plnRskAssMitChrCnt" class="outputLabel"> <span id="svapdxD1_5:plnRskAssMitChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxD1_5:plnRskAssMitChrCnt" type="text" name="svapdxD1_5:plnRskAssMitChrCnt" class="chrCnt" size="6" /><span id="svapdxD1_5:plnRskAssMitChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxD1_5:panel_plnRskAssMit"><textarea id="svapdxD1_5:plnRskAssMit" name="svapdxD1_5:plnRskAssMit" class="inputTextareaLong" onkeyup="Count(this);" readonly="readonly">The responsibility to assure health and welfare is balanced with the waiver participant's right to select their providers. It is imperative to accurately identify the services and supports that are needed to ensure the health and welfare of the waiver participant. During the service plan development process, the care manager, the consumer and his/her conservator, and any other person identified by the consumer collaborate to assess the consumer's ADL needs as well as any risk factors including: inadequate supervision, social isolation, inability to summon assistance, emotional and behavioral issues, and communication capabilities. This information is used to provide the background necessary to identify area of potential risk to the waiver participant. When risk issues are identified, the care manager will discuss this issue with their Supervisor and then provide feedback to the waiver participant regarding the area(s) of concern. This allows the consumer and the care manager to have a dialogue and exchange of ideas on how to mitigate the risk by developing a back up plan in collaboration with the consumer. The waiver participant has the right to accept, reject or modify recommendations that address risk. In addition, all participants are required to have, and document on the service plan, an emergency back up plan, if a provider does not report to work. If a waiver participant's choices are such that the waiver program is concerned that it will not be able to assure the waiver participant's health and welfare, this concern is clearly discussed with the waiver participant. If the waiver participant's health and welfare can be assured, then the waiver participant can remain on the waiver. Rist mitigation procedures and documents are completed. If this is not sufficiently mitigate risk, then the waiver participant is issued a Notice of Action (NOA), indicating discontinuance from the waiver. The consumer is informed that they have a right to a fair hearing, pursuant to Medicaid rules and the NOA includes information about their right to a fair hearing.</textarea></span> </div> </li> </ol> <H2 id="pageTitle">Appendix D: Participant-Centered Planning and Service Delivery</H2> <H3 id="pageSubTitle">D-1: Service Plan Development <span id="pageNumber">(6 of 8)</span></H3> <ol class="alphaLC" start="6"> <li> <div class="outputTextNB"> <strong>Informed Choice of Providers.</strong> <label id="svapdxD1_6:lbl_plnPrvdrChoProc" for="svapdxD1_6:plnPrvdrChoProc" class="outputLabel"> <span id="svapdxD1_6:lbltxt_plnPrvdrChoProc" class="outputTextNB">Describe how participants are assisted in obtaining information about and selecting from among qualified providers of the waiver services in the service plan.</span></label> <p></p> </div> <div class="chrCntDiv"> <label id="svapdxD1_6:plnPrvdrChoProcChrCntLbl" for="svapdxD1_6:plnPrvdrChoProcChrCnt" class="outputLabel"> <span id="svapdxD1_6:plnPrvdrChoProcChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxD1_6:plnPrvdrChoProcChrCnt" type="text" name="svapdxD1_6:plnPrvdrChoProcChrCnt" class="chrCnt" size="6" /><span id="svapdxD1_6:plnPrvdrChoProcChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxD1_6:panel_plnPrvdrChoProc"><textarea id="svapdxD1_6:plnPrvdrChoProc" name="svapdxD1_6:plnPrvdrChoProc" class="inputTextareaLong" onkeyup="Count(this);" readonly="readonly">Care managers share with waiver consumers the provider listing, which is developed by a DSS contracted fiduciary. This listing identifies providers and geographic locations. Consumers may also choose to hire the individual of their choosing and the fiscal intermediary reviews their qualifications. Additionally, a background check is conducted by the fiscal intermediary and the results are shared with the consumer to aid in their selection. PCAs would not be included in the list of waiver providers however the care manager who would also be assisting the client with the application for CFC could provide the PCA directory to the client as well. The care managers who do the waiver assessments are the same providers who will be doing the CFC assessments.</textarea></span> </div> </li> </ol> <H2 id="pageTitle">Appendix D: Participant-Centered Planning and Service Delivery</H2> <H3 id="pageSubTitle">D-1: Service Plan Development <span id="pageNumber">(7 of 8)</span></H3> <ol class="alphaLC" start="7"> <li> <div class="outputTextNB"> <strong>Process for Making Service Plan Subject to the Approval of the Medicaid Agency.</strong> <label id="svapdxD1_7:lbl_plnMedApvlProc" for="svapdxD1_7:plnMedApvlProc" class="outputLabel"> <span id="svapdxD1_7:lbltxt_plnMedApvlProc" class="outputTextNB">Describe the process by which the service plan is made subject to the approval of the Medicaid agency in accordance with 42 CFR &sect;441.301(b)(1)(i):</span></label> <p></p> </div> <div class="chrCntDiv"> <label id="svapdxD1_7:plnMedApvlProcChrCntLbl" for="svapdxD1_7:plnMedApvlProcChrCnt" class="outputLabel"> <span id="svapdxD1_7:plnMedApvlProcChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxD1_7:plnMedApvlProcChrCnt" type="text" name="svapdxD1_7:plnMedApvlProcChrCnt" class="chrCnt" size="6" /><span id="svapdxD1_7:plnMedApvlProcChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxD1_7:panel_plnMedApvlProc"><textarea id="svapdxD1_7:plnMedApvlProc" name="svapdxD1_7:plnMedApvlProc" class="inputTextareaLong" onkeyup="Count(this);" readonly="readonly">The staff of DSS, Connecticut's Medicaid agency, directly approves the developed service plan.</textarea></span> </div> </li> </ol> <H2 id="pageTitle">Appendix D: Participant-Centered Planning and Service Delivery</H2> <H3 id="pageSubTitle">D-1: Service Plan Development <span id="pageNumber">(8 of 8)</span></H3> <OL class="alphaLC" start="8"> <LI> <div class="outputTextNB"> <strong>Service Plan Review and Update.</strong> The service plan is subject to at least annual periodic review and update to assess the appropriateness and adequacy of the services as participant needs change. <label id="svapdxD1_8:lbl_plnRevUpdSch" for="svapdxD1_8:plnRevUpdSch" class="outputLabel"> <span id="svapdxD1_8:lbltxt_plnRevUpdSch" class="outputTextNB">Specify the minimum schedule for the review and update of the service plan:</span></label><table id="svapdxD1_8:plnRevUpdSch" class="selectOneRadio"> <tr> <td> <input type="radio" name="svapdxD1_8:plnRevUpdSch" id="svapdxD1_8:plnRevUpdSch:0" value="0" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxD1_8:plnRevUpdSch:0"> Every three months or more frequently when necessary</label></td> </tr> <tr> <td> <input type="radio" checked="checked" name="svapdxD1_8:plnRevUpdSch" id="svapdxD1_8:plnRevUpdSch:1" value="1" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxD1_8:plnRevUpdSch:1"> Every six months or more frequently when necessary</label></td> </tr> <tr> <td> <input type="radio" name="svapdxD1_8:plnRevUpdSch" id="svapdxD1_8:plnRevUpdSch:2" value="2" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxD1_8:plnRevUpdSch:2"> Every twelve months or more frequently when necessary</label></td> </tr> <tr> <td> <input type="radio" name="svapdxD1_8:plnRevUpdSch" id="svapdxD1_8:plnRevUpdSch:3" value="3" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxD1_8:plnRevUpdSch:3"> Other schedule</label></td> </tr> </table> <div class="firstIndent"> <label id="svapdxD1_8:lbl_plnOthSchDscr" for="svapdxD1_8:plnOthSchDscr" class="outputLabel"> <span id="svapdxD1_8:lbltxt_plnOthSchDscr" class="outputTextNB em">Specify the other schedule:</span></label> <p></p> <div class="chrCntDiv"> <label id="svapdxD1_8:plnOthSchDscrChrCntLbl" for="svapdxD1_8:plnOthSchDscrChrCnt" class="outputLabel"> <span id="svapdxD1_8:plnOthSchDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxD1_8:plnOthSchDscrChrCnt" type="text" name="svapdxD1_8:plnOthSchDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxD1_8:plnOthSchDscrChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxD1_8:panel_plnOthSchDscr"><textarea id="svapdxD1_8:plnOthSchDscr" name="svapdxD1_8:plnOthSchDscr" class="inputTextarea15" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> </div> </LI> <LI> <div class="outputTextNB"> <strong>Maintenance of Service Plan Forms.</strong> Written copies or electronic facsimiles of service plans are maintained for a minimum period of 3 years as required by 45 CFR §92.42. Service plans are maintained by the following <em>(check each that applies):</em> </div> <div class="checkboxGroup"> <input id="svapdxD1_8:plnFrmsMntMed" type="checkbox" name="svapdxD1_8:plnFrmsMntMed" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxD1_8:lblplnFrmsMntMed" for="svapdxD1_8:plnFrmsMntMed" class="outputLabel"> <span id="svapdxD1_8:lbltxt_plnFrmsMntMed" class="outputText">Medicaid agency</span></label> </div> <div class="checkboxGroup"> <input id="svapdxD1_8:plnFrmsMntOpAg" type="checkbox" name="svapdxD1_8:plnFrmsMntOpAg" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxD1_8:lblplnFrmsMntOpAg" for="svapdxD1_8:plnFrmsMntOpAg" class="outputLabel"> <span id="svapdxD1_8:lbltxt_plnFrmsMntOpAg" class="outputText">Operating agency</span></label> </div> <div class="checkboxGroup"> <input id="svapdxD1_8:plnFrmsMntCsMgr" type="checkbox" name="svapdxD1_8:plnFrmsMntCsMgr" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxD1_8:lblplnFrmsMntCsMgr" for="svapdxD1_8:plnFrmsMntCsMgr" class="outputLabel"> <span id="svapdxD1_8:lbltxt_plnFrmsMntCsMgr" class="outputText">Case manager</span></label> </div> <div class="checkboxGroup"> <input id="svapdxD1_8:plnFrmsMntOth" type="checkbox" name="svapdxD1_8:plnFrmsMntOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxD1_8:lblplnFrmsMntOth" for="svapdxD1_8:plnFrmsMntOth" class="outputLabel"> <span id="svapdxD1_8:lbltxt_plnFrmsMntOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxD1_8:lblplnFrmsMntOthDscr" for="svapdxD1_8:plnFrmsMntOthDscr" class="outputLabel"> <span id="svapdxD1_8:lbltxt_plnFrmsMntOthDscr" class="outputTextNB em">Specify:</span></label> <p></p> <div class="chrCntDiv"> <label id="svapdxD1_8:plnFrmsMntOthDscrChrCntLbl" for="svapdxD1_8:plnFrmsMntOthDscrChrCnt" class="outputLabel"> <span id="svapdxD1_8:plnFrmsMntOthDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxD1_8:plnFrmsMntOthDscrChrCnt" type="text" name="svapdxD1_8:plnFrmsMntOthDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxD1_8:plnFrmsMntOthDscrChrCntMax" class="chrCnt"> out of 4000</span> </div> <div class="inputTextareaWA"> <span id="svapdxD1_8:panel_plnFrmsMntOthDscr"><textarea id="svapdxD1_8:plnFrmsMntOthDscr" name="svapdxD1_8:plnFrmsMntOthDscr" class="inputTextarea15" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> </LI> </OL> <H2 id="pageTitle">Appendix D: Participant-Centered Planning and Service Delivery</H2> <H3 id="pageSubTitle">D-2: Service Plan Implementation and Monitoring</H3> <ol class="alphaLC" start="1"> <LI> <div class="outputTextNB"> <strong>Service Plan Implementation and Monitoring.</strong> <label id="svapdxD2_1:lbl_plnImplMon" for="svapdxD2_1:plnImplMon" class="outputLabel"> <span id="svapdxD2_1:lbltxt_plnImplMon" class="outputTextNB">Specify: (a) the entity (entities) responsible for monitoring the implementation of the service plan and participant health and welfare; (b) the monitoring and follow-up method(s) that are used; and, (c) the frequency with which monitoring is performed.</span></label> <p></p> </div> <div class="chrCntDiv"> <label id="svapdxD2_1:plnImplMonChrCntLbl" for="svapdxD2_1:plnImplMonChrCnt" class="outputLabel"> <span id="svapdxD2_1:plnImplMonChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxD2_1:plnImplMonChrCnt" type="text" name="svapdxD2_1:plnImplMonChrCnt" class="chrCnt" size="6" /><span id="svapdxD2_1:plnImplMonChrCntMax" class="chrCnt"> out of 24000</span> </div> <div class="inputTextareaWA"> <span id="svapdxD2_1:panel_plnImplMon"><textarea id="svapdxD2_1:plnImplMon" name="svapdxD2_1:plnImplMon" class="inputTextarea15" onkeyup="Count(this);" readonly="readonly">Care managers are responsible for the development, management, administration, and monitoring of the HCBS waiver participant. The care manager promotes participant choice, ensures the delivery of high quality services; assists in the development of needed services and oversees waiver cost-effectiveness, with the support of the agency supervisors and Alternate Care Unit staff. DSS through the Alternate Care Unit, Medical Operations, Quality Assurance, and the Department of Rehabilitation Services is the central component in managing and delivering the program objectives of deinstitutionalization, diversion and waiver administration. DSS is responsible for implementing the HCBS waiver and facilitating access to waiver program supports for eligible individuals. Monitoring Methods and frequency: A comprehensive plan of care is developed within 60 days of waiver eligibility. Discharge from institutional care and receipt of community-based services from providers must occur within 90 days. During this process a Access Agency care manager will consult with a client/representative via telephone or in person to monitor the client's plan and service needs. If the client or the care manager identify any problems during the service plan implementation process, the care manager will conduct a home visit to re-assess the level of care needs. The plan would be resubmitted to the Alternate Care Unit for approval. Particpants with 5 ADL support needs require additional review by Alternate Care Unit staff staff. If the clients needs are assessed as being more than can safely be provided by the waiver, the client is issued a notice of action and is afforded the right to a fair hearing. The care manager, consumer, and the consumer'’s conservator and/or supports meet a minimum of semi-annually to evaluate the plan. If however, at any time a consumer reports that a service plan is no longer effective, care managers will conduct a home visit to re-evaluate the level of care necessary to maintain the client safely in the community. With the addition of care management as a service, the department has set the expectation for the care manager to contact the client at least monthly and conduct a face-to-face visit every six months.</textarea></span> </div> </LI> <LI> <div class="outputTextNB"> <strong>Monitoring Safeguards.</strong> <em>Select one:</em> <table id="svapdxD2_1:plnMonOthSvcAllwd" class="selectOneRadio"> <tr> <td> <input type="radio" checked="checked" name="svapdxD2_1:plnMonOthSvcAllwd" id="svapdxD2_1:plnMonOthSvcAllwd:0" value="0" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxD2_1:plnMonOthSvcAllwd:0"> Entities and/or individuals that have responsibility to monitor service plan implementation and participant health and welfare may not provide other direct waiver services to the participant.</label></td> </tr> <tr> <td> <input type="radio" name="svapdxD2_1:plnMonOthSvcAllwd" id="svapdxD2_1:plnMonOthSvcAllwd:1" value="1" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxD2_1:plnMonOthSvcAllwd:1"> Entities and/or individuals that have responsibility to monitor service plan implementation and participant health and welfare may provide other direct waiver services to the participant.</label></td> </tr> </table> <div class="firstIndent"> <label id="svapdxD2_1:lbl_plnMonOthSvcSfg" for="svapdxD2_1:plnMonOthSvcSfg" class="outputLabel"> <span id="svapdxD2_1:lbltxt_plnMonOthSvcSfg1" class="outputTextNB">The State has established the following safeguards to ensure that monitoring is conducted in the best interests of the participant.</span><span id="svapdxD2_1:lbltxt_plnMonOthSvcSfg2" class="outputTextNB em"> Specify:</span></label> <p></p> <div class="chrCntDiv"> <label id="svapdxD2_1:plnMonOthSvcSfgChrCntLbl" for="svapdxD2_1:plnMonOthSvcSfgChrCnt" class="outputLabel"> <span id="svapdxD2_1:plnMonOthSvcSfgChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxD2_1:plnMonOthSvcSfgChrCnt" type="text" name="svapdxD2_1:plnMonOthSvcSfgChrCnt" class="chrCnt" size="6" /><span id="svapdxD2_1:plnMonOthSvcSfgChrCntMax" class="chrCnt"> out of 24000</span> </div> <div class="inputTextareaWA"> <span id="svapdxD2_1:panel_plnMonOthSvcSfg"><textarea id="svapdxD2_1:plnMonOthSvcSfg" name="svapdxD2_1:plnMonOthSvcSfg" class="inputTextarea15" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> </div> </LI> </ol> <H2 id="pageTitle">Appendix D: Participant-Centered Planning and Service Delivery</H2> <H3 id="pageSubTitle">Quality Improvement: Service Plan</H3> <div class="paragraph"> <span class="outputTextNB em"> As a distinct component of the State’s quality improvement strategy, provide information in the following fields to detail the State’s methods for discovery and remediation. </span> </div> <ol class="alphaLC" id="BQa" start="1" > <li style="margin-top: 1em;"> <div class="paragraph"> <span class="outputText">Methods for Discovery: Service Plan Assurance/Sub-assurances</span> <p class="pph"> <span class="outputText em">The state demonstrates it has designed and implemented an effective system for reviewing the adequacy of service plans for waiver participants.</span> </p> </div> <ol class="romanLC" id="BQai" start="1"> <li> <!-- a.i. --> <div>Sub-Assurances:</div> <ol class="alphaLC" start="1"> <li style="padding-bottom: 1em;"> <!-- a.i.a --> <div> <p> <span id="svapdxDQ_1:aiaSA" class="outputText em">Sub-assurance: Service plans address all participants’ assessed needs (including health and safety risk factors) and personal goals, either by the provision of waiver services or through other means.</span> </p> <p class="pph"> <span class="outputText">Performance Measures</span> </p> <p class="pph"> <span id="svapdxDQ_1:aiaPMInfo1" class="outputTextNB em">For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.</span> </p> <p class="pph"> <span id="svapdxDQ_1:aiaPMInstr1" class="outputTextNB em ul">For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.</span> </p> </div> <div class=""> <table id="svapdxDQ_1:dtPMPrnt_spa" class="nstTableX" summary="Expanded dynamic table for services" ><tbody > <tr ><td > <div style="padding-bottom: 1.5em; width:90%;" > <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:pmName" class="inputTextPct">The number and percent of individuals who report they are satisfied with the services they receive to ensure that their assessed needs including health and safety are met. The numerator is the number of participants who are satisfied and the denominator is the number surveyed</span> </div> </div> <table id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource" style="width: 90%" class="nstTableX" border="0" cellpadding="2" cellspacing="0" summary="dynamic table for Performance Measure Data Sources" ><tbody > <tr ><td ><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Analyzed collected data (including surveys, focus group, interviews, etc)</span><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct"></span></div></div></div><table id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:pmPnlGrdChkboxSet" class="nstTableX" border="1" cellpadding="3" cellspacing="0" style="vertical-align: top; margin-bottom: 1.5em;"> <tbody> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsSaPct" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaLtPct" class="outputText">Less than 100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsSaRs" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="inputTextarea" readonly="readonly">4.82</textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="inputTextarea" readonly="readonly">fiscal intermediary</textarea></span></div></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsFdCo" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsSaOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsFdOt" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="inputTextarea" readonly="readonly">twice per waiver renewal</textarea></span></div></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:0:dssa6"></span></td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <div style="padding: 1em 0 1em 0;"> </div> <div> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:pmDAA" class="outputText" style="margin-top: 1.5em;">Data Aggregation and Analysis:</span> </div> <table id="pmPnlGrdChkboxSet" class="nstTableX" id="pmPnlGrdChkboxSet"cellpadding="3" cellspacing="0" border="1" style="vertical-align: top; width: 85%;"> <THEAD><tr align="left" valign="top"> <th id="rp" class="third"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:txtPMfom2" class="outputTextNB em">(check each that applies):</span> </th> </tr></THEAD> <TBODY valign="top" align="left"> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:pmDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:pmDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:pmDaFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:pmDaRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:pmDaRpOthDsc" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:pmDaRpOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:pmDaFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:txtlbl_pmDaFdAn" class="outputText">Annually</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:pmDaFdCo" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:txtlblpmDaFdCo" class="outputText">Continuously and Ongoing</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup" > <input id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:pmDaFdOt" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:pmDaFdOtDsc" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:pmDaFdOtDsc" class="inputTextarea" readonly="readonly">twice per waiver renewal</textarea></span> </div> </div> </td> </tr> </TBODY> </table> <div> </div> </td> </tr> </tbody> </table> </div> </li> <li style="padding-bottom: 1em;"> <!-- a.i.b --> <div> <p> <span id="svapdxDQ_1:aibSA" class="outputText em">Sub-assurance: The State monitors service plan development in accordance with its policies and procedures. </span> </p> <p class="pph"> <span class="outputText">Performance Measures</span> </p> <p class="pph"> <span id="svapdxDQ_1:aibPMInfo1" class="outputTextNB em">For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.</span> </p> <p class="pph"> <span id="svapdxDQ_1:aibPMInstr1" class="outputTextNB em ul">For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.</span> </p> </div> <div class=""> <table id="svapdxDQ_1:dtPMPrnt_spb" class="nstTableX" summary="Expanded dynamic table for services" ><tbody > <tr ><td > <div style="padding-bottom: 1.5em; width:90%;" > <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:pmName" class="inputTextPct">Number and Percent of service plans are reviewed at the Alternate Care Unit prior to approval to ensure compliance with number of ADL's, Cost of Care caps and Medicaid eligibility. Numerator = number of service plans in compliance Denominator = total number of services plans reviewed at a supervisory and Central Office level.</span> </div> </div> <table id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource" style="width: 90%" class="nstTableX" border="0" cellpadding="2" cellspacing="0" summary="dynamic table for Performance Measure Data Sources" ><tbody > <tr ><td ><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Record reviews, on-site</span><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct"></span></div></div></div><table id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:pmPnlGrdChkboxSet" class="nstTableX" border="1" cellpadding="3" cellspacing="0" style="vertical-align: top; margin-bottom: 1.5em;"> <tbody> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsSaPct" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaLtPct" class="outputText">Less than 100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsFdCo" checked="checked" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsSaOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:0:dssa6"></span></td> </tr> </tbody> </table> </td> </tr> <tr ><td ><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsTypeLbl" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsType"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsTypeDDDiv"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsType" class="inputText">Record reviews, off-site</span><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsOtherNamelblDiv"><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsNameLbl" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsName"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:panel_dsName"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsName" class="inputTextPct"></span></div></div></div><table id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:pmPnlGrdChkboxSet" class="nstTableX" border="1" cellpadding="3" cellspacing="0" style="vertical-align: top; margin-bottom: 1.5em;"> <tbody> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsrp1"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:PMrp1div" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsRpSma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:lbl_dsRpSma" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsRpSma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsfom1"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsFdWkdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsFdWk" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:lbl_dsFdWk" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsFdWk" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dssa1"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsSaPctdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsSaPct" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsSaPct" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:lbl_dsSaPct" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsSaPct" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsrp2"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsRpOpadiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsRpOpa" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:lbl_dsRpOpa" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsRpOpa" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsfom2"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsFdModiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsFdMo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:lbl_dsFdMo" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsFdMo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dssa2"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsSaLtPct" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsSaLtPct" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:lbl_dsSaLtPct" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsSaLtPct" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsSaLtPct" class="outputText">Less than 100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsrp3"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsRpCmadiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsRpCma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:lbl_dsRpCma" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsRpCma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsfom3"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsFdQudiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsFdQu" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:lbl_dsFdQu" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsFdQu" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dssa3" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsSaRsdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsSaRs" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:lbl_dsSaRs" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsSaRs" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:lbl2_dsSaRsDsc" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsSaRsDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:panel_dsSaRsDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsSaRsDsc" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsSaRsDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsrp4"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsRpOthdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsRpOth" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:lbl_dsRpOth" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsRpOth" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:lbl2_dsRpOthDsc" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsRpOthDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:panel_dsRpOthDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsRpOthDsc" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsRpOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsfom4"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsFdAndiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsFdAn" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:lbl_dsFdAn" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsFdAn" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dssa4" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsSaStrdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsSaStr" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:lbl_dsSaStr" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsSaStr" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:lbl2_dsSaStrDsc" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsSaStrDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:panel_dsSaStrDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsSaStrDsc" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsSaStrDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsrp5"></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsfom5"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsFdCodiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsFdCo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsFdCo" checked="checked" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:lbl_dsFdCo" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsFdCo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dssa5" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsSaOthdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsSaOth" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsSaOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:lbl_dsSaOth" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsSaOth" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:lbl2_dsSaOthDsc" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsSaOthDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:panel_dsSaOthDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsSaOthDsc" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsSaOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsrp6"></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsfom6"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsFdOtdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsFdOt" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:lbl_dsFdOt" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsFdOt" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:lbl2_dsFdOtDsc" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsFdOtDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:panel_dsFdOtDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsFdOtDsc" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:dtDataSource:1:dssa6"></span></td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <div style="padding: 1em 0 1em 0;"> </div> <div> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:pmDAA" class="outputText" style="margin-top: 1.5em;">Data Aggregation and Analysis:</span> </div> <table id="pmPnlGrdChkboxSet" class="nstTableX" id="pmPnlGrdChkboxSet"cellpadding="3" cellspacing="0" border="1" style="vertical-align: top; width: 85%;"> <THEAD><tr align="left" valign="top"> <th id="rp" class="third"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:txtPMfom2" class="outputTextNB em">(check each that applies):</span> </th> </tr></THEAD> <TBODY valign="top" align="left"> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:pmDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:pmDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:pmDaFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:pmDaRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:pmDaRpOthDsc" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:pmDaRpOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:pmDaFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:txtlbl_pmDaFdAn" class="outputText">Annually</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:pmDaFdCo" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:txtlblpmDaFdCo" class="outputText">Continuously and Ongoing</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup" > <input id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:pmDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:pmDaFdOtDsc" name="svapdxDQ_1:dtPMPrnt_spb:0:svQmPerfMeas:pmDaFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> </tr> </TBODY> </table> <div> </div> </td> </tr> </tbody> </table> </div> </li> <li style="padding-bottom: 1em;"> <!-- a.i.c --> <div> <p> <span id="svapdxDQ_1:aicSA" class="outputText em">Sub-assurance: Service plans are updated/revised at least annually or when warranted by changes in the waiver participant’s needs.</span> </p> <p class="pph"> <span class="outputText">Performance Measures</span> </p> <p class="pph"> <span id="svapdxDQ_1:aicPMInfo1" class="outputTextNB em">For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.</span> </p> <p class="pph"> <span id="svapdxDQ_1:aicPMInstr1" class="outputTextNB em ul">For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.</span> </p> </div> <div class=""> <table id="svapdxDQ_1:dtPMPrnt_spc" class="nstTableX" summary="Expanded dynamic table for services" ><tbody > <tr ><td > <div style="padding-bottom: 1.5em; width:90%;" > <span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:pmName" class="inputTextPct">Number and Percent of Services System reports will be generatd monthly to identify outstanding reviews. Numerator = service system reports will be generated monthly to identify outstanding reviews. Denominator = total number of reports recieved.</span> </div> </div> <table id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource" style="width: 90%" class="nstTableX" border="0" cellpadding="2" cellspacing="0" summary="dynamic table for Performance Measure Data Sources" ><tbody > <tr ><td ><label id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Other</span><div id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct">System ad hoc reports</span></div></div></div><table id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:pmPnlGrdChkboxSet" class="nstTableX" border="1" cellpadding="3" cellspacing="0" style="vertical-align: top; margin-bottom: 1.5em;"> <tbody> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsSaPct" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsFdMo" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaLtPct" class="outputText">Less than 100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsFdCo" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsSaOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:dtDataSource:0:dssa6"></span></td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <div style="padding: 1em 0 1em 0;"> </div> <div> <span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:pmDAA" class="outputText" style="margin-top: 1.5em;">Data Aggregation and Analysis:</span> </div> <table id="pmPnlGrdChkboxSet" class="nstTableX" id="pmPnlGrdChkboxSet"cellpadding="3" cellspacing="0" border="1" style="vertical-align: top; width: 85%;"> <THEAD><tr align="left" valign="top"> <th id="rp" class="third"> <span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:txtPMfom2" class="outputTextNB em">(check each that applies):</span> </th> </tr></THEAD> <TBODY valign="top" align="left"> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:pmDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:pmDaFdMo" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:pmDaFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:pmDaRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:pmDaRpOthDsc" name="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:pmDaRpOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:pmDaFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:txtlbl_pmDaFdAn" class="outputText">Annually</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:pmDaFdCo" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:txtlblpmDaFdCo" class="outputText">Continuously and Ongoing</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup" > <input id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:pmDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:pmDaFdOtDsc" name="svapdxDQ_1:dtPMPrnt_spc:0:svQmPerfMeas:pmDaFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> </tr> </TBODY> </table> <div> </div> </td> </tr> <tr ><td > <div style="padding-bottom: 1.5em; width:90%;" > <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:pmName" class="inputTextPct">The number and percent of service plans that are updated when warranted by changes in participants' need. Numerator is number of plans updated and the denominator is the total number of plans</span> </div> </div> <table id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource" style="width: 90%" class="nstTableX" border="0" cellpadding="2" cellspacing="0" summary="dynamic table for Performance Measure Data Sources" ><tbody > <tr ><td ><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Record reviews, on-site</span><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct"></span></div></div></div><table id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:pmPnlGrdChkboxSet" class="nstTableX" border="1" cellpadding="3" cellspacing="0" style="vertical-align: top; margin-bottom: 1.5em;"> <tbody> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsSaPct" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaLtPct" class="outputText">Less than 100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsSaRs" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="inputTextarea" readonly="readonly">95%</textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="inputTextarea" readonly="readonly">Fiscal intermediary</textarea></span></div></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsFdAn" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsFdCo" checked="checked" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsSaOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:0:dssa6"></span></td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <div style="padding: 1em 0 1em 0;"> </div> <div> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:pmDAA" class="outputText" style="margin-top: 1.5em;">Data Aggregation and Analysis:</span> </div> <table id="pmPnlGrdChkboxSet" class="nstTableX" id="pmPnlGrdChkboxSet"cellpadding="3" cellspacing="0" border="1" style="vertical-align: top; width: 85%;"> <THEAD><tr align="left" valign="top"> <th id="rp" class="third"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:txtPMfom2" class="outputTextNB em">(check each that applies):</span> </th> </tr></THEAD> <TBODY valign="top" align="left"> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:pmDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:pmDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:pmDaFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:pmDaRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:pmDaRpOthDsc" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:pmDaRpOthDsc" class="inputTextarea" readonly="readonly">Fiscal intermediary</textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:pmDaFdAn" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:txtlbl_pmDaFdAn" class="outputText">Annually</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:pmDaFdCo" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:txtlblpmDaFdCo" class="outputText">Continuously and Ongoing</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup" > <input id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:pmDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:pmDaFdOtDsc" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:pmDaFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> </tr> </TBODY> </table> <div> </div> </td> </tr> </tbody> </table> </div> </li> <li style="padding-bottom: 1em;"> <!-- a.i.d --> <div> <p> <span id="svapdxDQ_1:aidSA" class="outputText em">Sub-assurance: Services are delivered in accordance with the service plan, including the type, scope, amount, duration and frequency specified in the service plan.</span> </p> <p class="pph"> <span class="outputText">Performance Measures</span> </p> <p class="pph"> <span id="svapdxDQ_1:aidPMInfo1" class="outputTextNB em">For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.</span> </p> <p class="pph"> <span id="svapdxDQ_1:aidPMInstr1" class="outputTextNB em ul">For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.</span> </p> </div> <div class=""> <table id="svapdxDQ_1:dtPMPrnt_spd" class="nstTableX" summary="Expanded dynamic table for services" ><tbody > <tr ><td > <div style="padding-bottom: 1.5em; width:90%;" > <span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:pmName" class="inputTextPct">The number and percent of reports from the fiscal intermediary indicating the type, scope and frequency of services provided received on time and in accordance with contract requirements. Numerator is the reports received in compliance with contract requirements and the denominator is the total number of reports received</span> </div> </div> <table id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource" style="width: 90%" class="nstTableX" border="0" cellpadding="2" cellspacing="0" summary="dynamic table for Performance Measure Data Sources" ><tbody > <tr ><td ><label id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Reports to State Medicaid Agency on delegated</span><div id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct"></span></div></div></div><table id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:pmPnlGrdChkboxSet" class="nstTableX" border="1" cellpadding="3" cellspacing="0" style="vertical-align: top; margin-bottom: 1.5em;"> <tbody> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsRpSma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsSaPct" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaLtPct" class="outputText">Less than 100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsFdQu" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="inputTextarea" readonly="readonly">fiscal intermediary</textarea></span></div></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsFdCo" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsSaOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:dtDataSource:0:dssa6"></span></td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <div style="padding: 1em 0 1em 0;"> </div> <div> <span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:pmDAA" class="outputText" style="margin-top: 1.5em;">Data Aggregation and Analysis:</span> </div> <table id="pmPnlGrdChkboxSet" class="nstTableX" id="pmPnlGrdChkboxSet"cellpadding="3" cellspacing="0" border="1" style="vertical-align: top; width: 85%;"> <THEAD><tr align="left" valign="top"> <th id="rp" class="third"> <span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:txtPMfom2" class="outputTextNB em">(check each that applies):</span> </th> </tr></THEAD> <TBODY valign="top" align="left"> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:pmDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:pmDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:pmDaFdQu" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:pmDaRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:pmDaRpOthDsc" name="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:pmDaRpOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:pmDaFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:txtlbl_pmDaFdAn" class="outputText">Annually</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:pmDaFdCo" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:txtlblpmDaFdCo" class="outputText">Continuously and Ongoing</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup" > <input id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:pmDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:pmDaFdOtDsc" name="svapdxDQ_1:dtPMPrnt_spd:0:svQmPerfMeas:pmDaFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> </tr> </TBODY> </table> <div> </div> </td> </tr> </tbody> </table> </div> </li> <li style="padding-bottom: 1em;"> <!-- a.i.e --> <div> <p> <span id="svapdxDQ_1:aieSA" class="outputText em">Sub-assurance: Participants are afforded choice: Between/among waiver services and providers.</span> </p> <p class="pph"> <span class="outputText">Performance Measures</span> </p> <p class="pph"> <span id="svapdxDQ_1:aiePMInfo1" class="outputTextNB em">For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.</span> </p> <p class="pph"> <span id="svapdxDQ_1:aiePMInstr1" class="outputTextNB em ul">For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.</span> </p> </div> <div class=""> <table id="svapdxDQ_1:dtPMPrnt_spe" class="nstTableX" summary="Expanded dynamic table for services" ><tbody > <tr ><td > <div style="padding-bottom: 1.5em; width:90%;" > <span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:pmName" class="inputTextPct">The number and percent of participants who sign a Freedom of Choice/Hearing Notification form during the assessment process. Numerator is the number of participants who sign the freedom of choice form and the denominator is the total number or participants</span> </div> </div> <table id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource" style="width: 90%" class="nstTableX" border="0" cellpadding="2" cellspacing="0" summary="dynamic table for Performance Measure Data Sources" ><tbody > <tr ><td ><label id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Record reviews, on-site</span><div id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct"></span></div></div></div><table id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:pmPnlGrdChkboxSet" class="nstTableX" border="1" cellpadding="3" cellspacing="0" style="vertical-align: top; margin-bottom: 1.5em;"> <tbody> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsSaPct" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaLtPct" class="outputText">Less than 100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsFdCo" checked="checked" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsSaOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:dtDataSource:0:dssa6"></span></td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <div style="padding: 1em 0 1em 0;"> </div> <div> <span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:pmDAA" class="outputText" style="margin-top: 1.5em;">Data Aggregation and Analysis:</span> </div> <table id="pmPnlGrdChkboxSet" class="nstTableX" id="pmPnlGrdChkboxSet"cellpadding="3" cellspacing="0" border="1" style="vertical-align: top; width: 85%;"> <THEAD><tr align="left" valign="top"> <th id="rp" class="third"> <span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:txtPMfom2" class="outputTextNB em">(check each that applies):</span> </th> </tr></THEAD> <TBODY valign="top" align="left"> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:pmDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:pmDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:pmDaFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:pmDaRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:pmDaRpOthDsc" name="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:pmDaRpOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:pmDaFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:txtlbl_pmDaFdAn" class="outputText">Annually</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:pmDaFdCo" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:txtlblpmDaFdCo" class="outputText">Continuously and Ongoing</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup" > <input id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:pmDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:pmDaFdOtDsc" name="svapdxDQ_1:dtPMPrnt_spe:0:svQmPerfMeas:pmDaFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> </tr> </TBODY> </table> <div> </div> </td> </tr> </tbody> </table> </div> </li> </ol> </li> <li style="padding-top: 1.5em;"> <!-- a.ii. --> <div class="paragraph"> <label id="svapdxDQ_1:lbl_qmSpDiscDesc" for="svapdxDQ_1:qmSpDiscDesc" class="outputLabel"> <span id="svapdxDQ_1:txt_lbl_qmSpDiscDesc" class="outputTextNB">If applicable, in the textbox below provide any necessary additional information on the strategies employed by the State to discover/identify problems/issues within the waiver program, including frequency and parties responsible.</span></label> </div> <div></div> <div class="chrCntDiv"> <label id="svapdxDQ_1:qmSpDiscDescChrCntLbl" for="svapdxDQ_1:qmSpDiscDescChrCnt" class="outputLabel"> <span id="svapdxDQ_1:qmSpDiscDescChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxDQ_1:qmSpDiscDescChrCnt" type="text" name="svapdxDQ_1:qmSpDiscDescChrCnt" class="chrCnt" size="6" /><span id="svapdxDQ_1:qmSpDiscDescChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxDQ_1:panel_qmSpDiscDesc"><textarea id="svapdxDQ_1:qmSpDiscDesc" name="svapdxDQ_1:qmSpDiscDesc" class="inputTextarea" onkeyup="Count(this);" readonly="readonly">There is a system of checks and balances in place that all Service Plans must be approved by the Alternate Care Unit staff</textarea></span> </div> </li> </ol> </li> <li style="margin-top: 1em;"> <!-- b. --> <div class="paragraph"> <span class="outputText">Methods for Remediation/Fixing Individual Problems</span> </div> <ol class="romanLC" id="AQb" start="1"> <li> <!-- b.i. --> <div class="paragraph"> <label id="svapdxDQ_1:lbl_qmSpRemDesc" for="svapdxDQ_1:qmSpRemDesc" class="outputLabel"> <span id="svapdxDQ_1:txt_lbl_qmSpRemDesc" class="outputTextNB">Describe the State’s method for addressing individual problems as they are discovered. Include information regarding responsible parties and GENERAL methods for problem correction. In addition, provide information on the methods used by the State to document these items. </span></label> </div> <div></div> <div class="chrCntDiv"> <label id="svapdxDQ_1:qmSpRemDescChrCntLbl" for="svapdxDQ_1:qmSpRemDescChrCnt" class="outputLabel"> <span id="svapdxDQ_1:qmSpRemDescChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxDQ_1:qmSpRemDescChrCnt" type="text" name="svapdxDQ_1:qmSpRemDescChrCnt" class="chrCnt" size="6" /><span id="svapdxDQ_1:qmSpRemDescChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxDQ_1:panel_qmSpRemDesc"><textarea id="svapdxDQ_1:qmSpRemDesc" name="svapdxDQ_1:qmSpRemDesc" class="inputTextarea" onkeyup="Count(this);" readonly="readonly">The service plan assessment and review process works on a system of checks and balances. Documentation is reviewed by Access Agency supervisors until all parts of the service plan are complete, and are in compliance with the waiver requirements. Alternate Care staff authorize the plan before services are initiated. Questions regarding the plan are forwarded back to the access agency for further review and documentation. Should the consumer not agree with the service change they may request a fair hearing.</textarea></span> </div> </li> <li> <!-- b.ii. --> <div class="paragraph"> <span id="svapdxDQ_1:txt1">Remediation Data Aggregation</span> </div> <div> <span id="svapdxDQ_1:txt2">Remediation-related Data Aggregation and Analysis (including trend identification)</span> <table cellpadding="3" cellspacing="0" border="1" class="nstTableX" style="width: 88%;"> <thead align="left"> <tr> <th id="rp" style="width:44%;"> <span id="svapdxDQ_1:txtrp">Responsible Party</span><span id="svapdxDQ_1:txtrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" style="width:44%;"> <span id="svapdxDQ_1:txtfom">Frequency of data aggregation and analysis</span><span id="svapdxDQ_1:txtfom2" class="outputTextNB em">(check each that applies):</span> </th> </tr> </thead> <tbody align="left" valign="top"> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:qmSpDaRpSma" type="checkbox" name="svapdxDQ_1:qmSpDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:lbl_qmSpDaRpSma" for="svapdxDQ_1:qmSpDaRpSma" class="outputLabel"> <span id="svapdxDQ_1:txtlbl_qmSpDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:qmSpDaFdWk" type="checkbox" name="svapdxDQ_1:qmSpDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:lbl_qmSpDaFdWk" for="svapdxDQ_1:qmSpDaFdWk" class="outputLabel"> <span id="svapdxDQ_1:txtlbl_qmSpDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:qmSpDaRpOpa" type="checkbox" name="svapdxDQ_1:qmSpDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:lbl_qmSpDaRpOpa" for="svapdxDQ_1:qmSpDaRpOpa" class="outputLabel"> <span id="svapdxDQ_1:txtlbl_qmSpDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:qmSpDaFdMo" type="checkbox" name="svapdxDQ_1:qmSpDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:lbl_qmSpDaFdMo" for="svapdxDQ_1:qmSpDaFdMo" class="outputLabel"> <span id="svapdxDQ_1:txtlbl_qmSpDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:qmSpDaRpCma" type="checkbox" name="svapdxDQ_1:qmSpDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:lbl_qmSpDaRpCma" for="svapdxDQ_1:qmSpDaRpCma" class="outputLabel"> <span id="svapdxDQ_1:txtlbl_qmSpDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:qmSpDaFdQu" type="checkbox" name="svapdxDQ_1:qmSpDaFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:lbl_qmSpDaFdQu" for="svapdxDQ_1:qmSpDaFdQu" class="outputLabel"> <span id="svapdxDQ_1:txtlbl_qmSpDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:qmSpDaRpOth" type="checkbox" name="svapdxDQ_1:qmSpDaRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:lbl_qmSpDaRpOth" for="svapdxDQ_1:qmSpDaRpOth" class="outputLabel"> <span id="svapdxDQ_1:txtlbl_qmSpDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxDQ_1:lbl2_qmSpDaRpOthDsc" for="svapdxDQ_1:qmSpDaRpOthDsc" class="outputLabel"> <span id="svapdxDQ_1:txtlbl2_qmSpDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <p></p> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxDQ_1:panel_qmSpDaRpOthDsc"><textarea id="svapdxDQ_1:qmSpDaRpOthDsc" name="svapdxDQ_1:qmSpDaRpOthDsc" class="inputTextarea" readonly="readonly"></textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:qmSpDaFdAn" type="checkbox" name="svapdxDQ_1:qmSpDaFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:lbl_qmSpDaFdAn" for="svapdxDQ_1:qmSpDaFdAn" class="outputLabel"> <span id="svapdxDQ_1:txtlbl_qmSpDaFdAn" class="outputText">Annually</span></label> </div> </td> </tr> <tr> <td headers="rp"> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:qmSpDaFdCo" type="checkbox" name="svapdxDQ_1:qmSpDaFdCo" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxDQ_1:lbl_qmSpDaFdCo" for="svapdxDQ_1:qmSpDaFdCo" class="outputLabel"> <span id="svapdxDQ_1:txtlblqmSpDaFdCo" class="outputText">Continuously and Ongoing</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:qmSpDaFdOt" type="checkbox" name="svapdxDQ_1:qmSpDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxDQ_1:lbl_qmSpDaFdOt" for="svapdxDQ_1:qmSpDaFdOt" class="outputLabel"> <span id="svapdxDQ_1:txtlblqmSpDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxDQ_1:lbl2_qmSpDaFdOtDsc" for="svapdxDQ_1:qmSpDaFdOtDsc" class="outputLabel"> <span id="svapdxDQ_1:txtlbl2qmSpDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <p></p> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxDQ_1:panel_qmSpDaFdOtDsc"><textarea id="svapdxDQ_1:qmSpDaFdOtDsc" name="svapdxDQ_1:qmSpDaFdOtDsc" class="inputTextarea" readonly="readonly"></textarea></span> </div> </div> </td> </tr> </tbody> </table> </div> </li> </ol> </li> <li style="margin-top: 1em;"> <!-- c. --> <div> <span class="outputText">Timelines</span> </div> <div> <label id="svapdxDQ_1:lbl_qmSpTimeLn" for="svapdxDQ_1:qmSpTimeLn" class="outputLabel"> <span id="svapdxDQ_1:txt_lbl_qmSpTimeLn" class="outputTextNB">When the State does not have all elements of the Quality Improvement Strategy in place, provide timelines to design methods for discovery and remediation related to the assurance of Service Plans that are currently non-operational.</span></label> <div> <div class="checkboxGroup"><label><input id="svapdxDQ_1:qmSpTimeLn:1" type="radio" name="svapdxDQ_1:qmSpTimeLn" checked="checked" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;No</label></div> <div class="checkboxGroup"><label><input id="svapdxDQ_1:qmSpTimeLn:0" type="radio" name="svapdxDQ_1:qmSpTimeLn" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;Yes</label></div> <div class="noShow"><label><input id="svapdxDQ_1:qmSpTimeLn:2" type="radio" name="svapdxDQ_1:qmSpTimeLn" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </div> </div> <div class="firstIndent"> <label id="svapdxDQ_1:lbl_qmSpTimeLnDsc" for="svapdxDQ_1:qmSpTimeLnDsc" class="outputLabel"> <span id="svapdxDQ_1:txt_lbl_qmSpTimeLnDsc" class="outputTextNB">Please provide a detailed strategy for assuring Service Plans, the specific timeline for implementing identified strategies, and the parties responsible for its operation.</span></label> <div></div> <div class="chrCntDiv"> <label id="svapdxDQ_1:qmSpTimeLnDscChrCntLbl" for="svapdxDQ_1:qmSpTimeLnDscChrCnt" class="outputLabel"> <span id="svapdxDQ_1:qmSpTimeLnDscChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxDQ_1:qmSpTimeLnDscChrCnt" type="text" name="svapdxDQ_1:qmSpTimeLnDscChrCnt" class="chrCnt" size="6" /><span id="svapdxDQ_1:qmSpTimeLnDscChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxDQ_1:panel_qualc"><textarea id="svapdxDQ_1:qmSpTimeLnDsc" name="svapdxDQ_1:qmSpTimeLnDsc" class="inputTextarea" readonly="readonly"></textarea></span> </div> </div> </li> </ol> <H2 id="pageTitle">Appendix E: Participant Direction of Services</H2> <p class="outputTextNB"><strong>Applicability</strong> <em>(from Application Section 3, Components of the Waiver Request)</em>: </p> <div class="firstIndent outputText"> <div class="checkboxGroup"><label><input id="svapdxE0_1:particDirSvc:0" type="radio" name="svapdxE0_1:particDirSvc" checked="checked" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;Yes. This waiver provides participant direction opportunities.</label> <span class="outputTextNB">Complete the remainder of the Appendix.</span></div> <div class="checkboxGroup"><label><input id="svapdxE0_1:particDirSvc:1" type="radio" name="svapdxE0_1:particDirSvc" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;No. This waiver does not provide participant direction opportunities.</label> <span class="outputTextNB">Do not complete the remainder of the Appendix.</span></div> <div class="noShow"><label><input id="svapdxE0_1:particDirSvc:2" type="radio" name="svapdxE0_1:particDirSvc" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </div> <!-- rendered="#{(varFactory.particDirSvc == '0') ? true : false}"> --> <div class="pph"> <p class="outputTextNB pph"><em>CMS urges states to afford all waiver participants the opportunity to direct their services. Participant direction of services includes the participant exercising decision-making authority over workers who provide services, a participant-managed budget or both. CMS will confer the Independence Plus designation when the waiver evidences a strong commitment to participant direction.</em></p> <p class="outputTextNB"><Strong>Indicate whether Independence Plus designation is requested</Strong> <em>(select one):</em></p> <div class="firstIndent outputText"> <div class="checkboxGroup"><label><input id="svapdxE0_1:dosReqIndPlusDsgn:0" type="radio" name="svapdxE0_1:dosReqIndPlusDsgn" value="0" disabled="disabled" />&#160;Yes. The State requests that this waiver be considered for Independence Plus designation.</label></div> <div class="checkboxGroup"><label><input id="svapdxE0_1:dosReqIndPlusDsgn:1" type="radio" name="svapdxE0_1:dosReqIndPlusDsgn" checked="checked" value="1" disabled="disabled" />&#160;No. Independence Plus designation is not requested.</label></div> <div class="noShow"><label><input id="svapdxE0_1:dosReqIndPlusDsgn:2" type="radio" name="svapdxE0_1:dosReqIndPlusDsgn" value="99" disabled="disabled" />&#160;not selected</label></div> </div> </div> <H2 id="pageTitle">Appendix E: Participant Direction of Services</H2> <H3 id="pageSubTitle">E-1: Overview <SPAN id="pageNumber">(1 of 13)</SPAN></H3> <OL class="alphaLC" start="1"> <LI><p class="outputTextNB"> <STRONG>Description of Participant Direction.</STRONG> <label id="svapdxE1_1:lbl_dosOvrvw" for="svapdxE1_1:dosOvrvw" class="outputLabel"> <span id="svapdxE1_1:lbltxt_dosOvrvw" class="outputTextNB">In no more than two pages, provide an overview of the opportunities for participant direction in the waiver, including: (a) the nature of the opportunities afforded to participants; (b) how participants may take advantage of these opportunities; (c) the entities that support individuals who direct their services and the supports that they provide; and, (d) other relevant information about the waiver's approach to participant direction.</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxE1_1:dosOvrvwChrCntLbl" for="svapdxE1_1:dosOvrvwChrCnt" class="outputLabel"> <span id="svapdxE1_1:dosOvrvwChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxE1_1:dosOvrvwChrCnt" type="text" name="svapdxE1_1:dosOvrvwChrCnt" class="chrCnt" size="6" /><span id="svapdxE1_1:dosOvrvwChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxE1_1:panel_dosOvrvw"><textarea id="svapdxE1_1:dosOvrvw" name="svapdxE1_1:dosOvrvw" class="inputTextareaLong" onkeyup="Count(this);" readonly="readonly">Participants have the authority to and are supported to direct and manage their own services to the extent they are able. the service available under this waiver that can be self directed is the Independent support Broker. This service is available beyond the scope of what is offered under the 1915k state plan option. The care manager partners with the waiver participant, and anyone he/she chooses, in the development of the participant Service Plan. During the service plan development process the waiver participant is supported and encouraged to lead and fully participate in the process. Service plans are signed by the waiver participant and are maintained in each participant's file. Participants are the employer of record for PCAs under the 1915k and are responsible for hiring, firing, assignment of duties and signing of timesheets. Supports in these activities are provided under this waiver through the use of the independent support broker in a scope beyond what is offered under the CFC state plan option. If a consumer is unable or unwilling to do the above tasks they may appoint a representative to act on their behalf.</textarea></span> </div> </LI> </OL> <H2 id="pageTitle">Appendix E: Participant Direction of Services</H2> <H3 id="pageSubTitle">E-1: Overview <SPAN id="pageNumber">(2 of 13)</SPAN></H3> <OL class="alphaLC" start="2"> <LI> <p class="outputTextNB"><strong>Participant Direction Opportunities.</strong> Specify the participant direction opportunities that are available in the waiver. <em>Select one</em>: </p> <div class="checkboxGroup"> <label><input id="svapdxE1_2:dosPtcOppType:0" type="radio" name="svapdxE1_2:dosPtcOppType" checked="checked" value="0" disabled="disabled" />&#160;Participant: Employer Authority.</label> <span class="outputTextNB"> As specified in <STRONG><em>Appendix E-2, Item a</em></STRONG>, the participant (or the participant's representative) has decision-making authority over workers who provide waiver services. The participant may function as the common law employer or the co-employer of workers. Supports and protections are available for participants who exercise this authority. </span> </div> <div class="checkboxGroup"> <label><input id="svapdxE1_2:dosPtcOppType:1" type="radio" name="svapdxE1_2:dosPtcOppType" value="1" disabled="disabled" />&#160;Participant: Budget Authority.</label> <span class="outputTextNB"> As specified in <strong><em>Appendix E-2, Item b</em></strong>, the participant (or the participant's representative) has decision-making authority over a budget for waiver services. Supports and protections are available for participants who have authority over a budget. </span> </div> <div class="checkboxGroup"> <label><input id="svapdxE1_2:dosPtcOppType:2" type="radio" name="svapdxE1_2:dosPtcOppType" value="2" disabled="disabled" />&#160;Both Authorities.</label> <span class="outputTextNB"> The waiver provides for both participant direction opportunities as specified in <strong><em>Appendix E-2</em></strong>. Supports and protections are available for participants who exercise these authorities. </span> </div> <div class="noShow"><label><input id="svapdxE1_2:dosPtcOppType:3" type="radio" name="svapdxE1_2:dosPtcOppType" value="99" disabled="disabled" />&#160;not selected</label></div> </LI> <LI> <p class="outputTextNB"> <strong>Availability of Participant Direction by Type of Living Arrangement.</strong> <em>Check each that applies</em>: </p> <div class="checkboxGroup"> <input id="svapdxE1_2:dosLivArrFam" type="checkbox" name="svapdxE1_2:dosLivArrFam" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxE1_2:lbldosLivArrFam" for="svapdxE1_2:dosLivArrFam" class="outputLabel"> <span id="svapdxE1_2:lbltxt_dosLivArrFam" class="outputText">Participant direction opportunities are available to participants who live in their own private residence or the home of a family member.</span></label> </div> <div class="checkboxGroup"> <input id="svapdxE1_2:dosLivArrSm" type="checkbox" name="svapdxE1_2:dosLivArrSm" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxE1_2:lbldosLivArrSm" for="svapdxE1_2:dosLivArrSm" class="outputLabel"> <span id="svapdxE1_2:lbltxt_dosLivArrSm" class="outputText">Participant direction opportunities are available to individuals who reside in other living arrangements where services (regardless of funding source) are furnished to fewer than four persons unrelated to the proprietor.</span></label> </div> <div class="checkboxGroup"> <input id="svapdxE1_2:dosLivArrOth" type="checkbox" name="svapdxE1_2:dosLivArrOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxE1_2:lbldosLivArrOth" for="svapdxE1_2:dosLivArrOth" class="outputLabel"> <span id="svapdxE1_2:lbltxt_dosLivArrOth" class="outputText">The participant direction opportunities are available to persons in the following other living arrangements </span></label> </div> <div class="firstIndent"> <p> <label id="svapdxE1_2:lbldosLivArrOthDscr" for="svapdxE1_2:dosLivArrOthDscr" class="outputLabel"> <span id="svapdxE1_2:lbltxt_dosLivArrOthDscr" class="outputTextNB">Specify these living arrangements:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxE1_2:dosLivArrOthDscrChrCntLbl" for="svapdxE1_2:dosLivArrOthDscrChrCnt" class="outputLabel"> <span id="svapdxE1_2:dosLivArrOthDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxE1_2:dosLivArrOthDscrChrCnt" type="text" name="svapdxE1_2:dosLivArrOthDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxE1_2:dosLivArrOthDscrChrCntMax" class="chrCnt"> out of 4000</span> </div> <div class="inputTextareaWA"> <span id="svapdxE1_2:panel_dosLivArrOthDscr"><textarea id="svapdxE1_2:dosLivArrOthDscr" name="svapdxE1_2:dosLivArrOthDscr" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> </LI> </OL> <H2 id="pageTitle">Appendix E: Participant Direction of Services</H2> <H3 id="pageSubTitle">E-1: Overview <SPAN id="pageNumber">(3 of 13)</SPAN></H3> <OL class="alphaLC" start="4"> <LI> <p class="outputTextNB"> <strong>Election of Participant Direction.</strong> <label id="svapdxE1_3:lbldosElctn" for="svapdxE1_3:dosElctn" class="outputLabel"> <span id="svapdxE1_3:lbltxt_dosElctn1" class="outputTextNB">Election of participant direction is subject to the following policy</span><span id="svapdxE1_3:lbltxt_dosElctn2" class="outputTextNB em"> (select one):</span></label> </p> <table id="svapdxE1_3:dosElctn" class="selectOneRadio"> <tr> <td> <input type="radio" checked="checked" name="svapdxE1_3:dosElctn" id="svapdxE1_3:dosElctn:0" value="0" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxE1_3:dosElctn:0"> Waiver is designed to support only individuals who want to direct their services.</label></td> </tr> <tr> <td> <input type="radio" name="svapdxE1_3:dosElctn" id="svapdxE1_3:dosElctn:1" value="1" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxE1_3:dosElctn:1"> The waiver is designed to afford every participant (or the participant's representative) the opportunity to elect to direct waiver services. Alternate service delivery methods are available for participants who decide not to direct their services.</label></td> </tr> <tr> <td> <input type="radio" name="svapdxE1_3:dosElctn" id="svapdxE1_3:dosElctn:2" value="2" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxE1_3:dosElctn:2"> The waiver is designed to offer participants (or their representatives) the opportunity to direct some or all of their services, subject to the following criteria specified by the State. Alternate service delivery methods are available for participants who decide not to direct their services or do not meet the criteria.</label></td> </tr> </table> <!-- rendered="#{(varFactory.dosElctn == '2') ? true : false}"> --> <div class="firstIndent"> <p> <label id="svapdxE1_3:lbldosElctnCrit" for="svapdxE1_3:dosElctnCrit" class="outputLabel"> <span id="svapdxE1_3:lbltxt_dosElctnCrit" class="outputTextNB em">Specify the criteria</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxE1_3:dosElctnCritChrCntLbl" for="svapdxE1_3:dosElctnCritChrCnt" class="outputLabel"> <span id="svapdxE1_3:dosElctnCritChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxE1_3:dosElctnCritChrCnt" type="text" name="svapdxE1_3:dosElctnCritChrCnt" class="chrCnt" size="6" /><span id="svapdxE1_3:dosElctnCritChrCntMax" class="chrCnt"> out of 18000</span> </div> <div class="inputTextareaWA"> <span id="svapdxE1_3:panel_dosElctnCrit"><textarea id="svapdxE1_3:dosElctnCrit" name="svapdxE1_3:dosElctnCrit" class="inputTextareaLong" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> </LI> </OL> <H2 id="pageTitle">Appendix E: Participant Direction of Services</H2> <H3 id="pageSubTitle">E-1: Overview <SPAN id="pageNumber">(4 of 13)</SPAN></H3> <OL class="alphaLC" start="5"> <LI> <p class="outputTextNB"> <strong>Information Furnished to Participant. </strong> <label id="svapdxE1_4:lbldosInfo" for="svapdxE1_4:dosInfo" class="outputLabel"> <span id="svapdxE1_4:lbltxt_dosInfo" class="outputTextNB">Specify: (a) the information about participant direction opportunities (e.g., the benefits of participant direction, participant responsibilities, and potential liabilities) that is provided to the participant (or the participant's representative) to inform decision-making concerning the election of participant direction; (b) the entity or entities responsible for furnishing this information; and, (c) how and when this information is provided on a timely basis.</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxE1_4:dosInfoChrCntLbl" for="svapdxE1_4:dosInfoChrCnt" class="outputLabel"> <span id="svapdxE1_4:dosInfoChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxE1_4:dosInfoChrCnt" type="text" name="svapdxE1_4:dosInfoChrCnt" class="chrCnt" size="6" /><span id="svapdxE1_4:dosInfoChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxE1_4:panel_doxInfo"><textarea id="svapdxE1_4:dosInfo" name="svapdxE1_4:dosInfo" class="inputTextareaLong" onkeyup="Count(this);" readonly="readonly">Prior to the application process clients are directed to call the department's central office to inquire about the PCA waiver program. During this phone consult, the consumer is provided with information about the PCA waiver which includes the self direction requirement prior to making application. The potential client is also engaged in a discussion about self-direction and should they not want to self direct they have the ability to appoint a representative and are at that time informed of the implications. The PCA waiver brochure is also mailed to the client as a part of this pre-application process and this allows the client to read more about the program and self direction. Once a client makes application, care managers and the fiscal intermediary, provide information to waiver consumers regarding participant direction. The fiscal intermediary provides training for the consumer or their representative to become an employer. This training allows the consumer to decide if they are willing and able to be employers and if not, to appoint a representative to do so.</textarea></span> </div> </LI> </OL> <H2 id="pageTitle">Appendix E: Participant Direction of Services</H2> <H3 id="pageSubTitle">E-1: Overview <SPAN id="pageNumber">(5 of 13)</SPAN></H3> <OL class="alphaLC" start="6"> <LI> <p class="outputTextNB"> <strong>Participant Direction by a Representative. </strong> <label id="svapdxE1_5:lbldosbyRep" for="svapdxE1_5:dosbyRep" class="outputLabel"> <span id="svapdxE1_5:lbltxt_dosbyRep1" class="outputTextNB">Specify the State's policy concerning the direction of waiver services by a representative </span><span id="svapdxE1_5:lbltxt_dosbyRep2" class="outputTextNB em"> (select one):</span></label> </p> <table id="svapdxE1_5:dosbyRep" class="selectOneRadio"> <tr> <td> <input type="radio" name="svapdxE1_5:dosbyRep" id="svapdxE1_5:dosbyRep:0" value="0" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxE1_5:dosbyRep:0"> The State does not provide for the direction of waiver services by a representative.</label></td> </tr> <tr> <td> <input type="radio" checked="checked" name="svapdxE1_5:dosbyRep" id="svapdxE1_5:dosbyRep:1" value="1" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxE1_5:dosbyRep:1"> The State provides for the direction of waiver services by representatives.</label></td> </tr> </table> <div class="firstIndent"> <!-- rendered="#{(varFactory.dosbyRep == '1') ? true : false}"> --> <p class="outputTextNB">Specify the representatives who may direct waiver services: <em>(check each that applies)</em>:</p> <div class="checkboxGroup"> <input id="svapdxE1_5:dosbyRepLeg" type="checkbox" name="svapdxE1_5:dosbyRepLeg" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxE1_5:lbldosbyRepLeg" for="svapdxE1_5:dosbyRepLeg" class="outputLabel"> <span id="svapdxE1_5:lbltxt_dosbyRepLeg" class="outputText">Waiver services may be directed by a legal representative of the participant.</span></label> </div> <div class="checkboxGroup"> <input id="svapdxE1_5:dosbyRepNonLeg" type="checkbox" name="svapdxE1_5:dosbyRepNonLeg" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxE1_5:lbldosbyRepNonLeg" for="svapdxE1_5:dosbyRepNonLeg" class="outputLabel"> <span id="svapdxE1_5:lbltxt_dosbyRepNonLeg" class="outputText">Waiver services may be directed by a non-legal representative freely chosen by an adult participant.</span></label> </div> <div class="firstIndent"> <label id="svapdxE1_5:lbldosbyRepNonLegPol" for="svapdxE1_5:dosbyRepNonLegPol" class="outputLabel"> <span id="svapdxE1_5:lbltxt_dosbyRepNonLegPol" class="outputTextNB">Specify the policies that apply regarding the direction of waiver services by participant-appointed representatives, including safeguards to ensure that the representative functions in the best interest of the participant:</span></label> <p></p> <div class="chrCntDiv"> <label id="svapdxE1_5:dosbyRepNonLegPolChrCntLbl" for="svapdxE1_5:dosbyRepNonLegPolChrCnt" class="outputLabel"> <span id="svapdxE1_5:dosbyRepNonLegPolChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxE1_5:dosbyRepNonLegPolChrCnt" type="text" name="svapdxE1_5:dosbyRepNonLegPolChrCnt" class="chrCnt" size="6" /><span id="svapdxE1_5:dosbyRepNonLegPolChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxE1_5:panel_dosbyRepNonLegPol"><textarea id="svapdxE1_5:dosbyRepNonLegPol" name="svapdxE1_5:dosbyRepNonLegPol" class="inputTextareaLong" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> </div> </LI> </OL> <H2 id="pageTitle">Appendix E: Participant Direction of Services</H2> <H3 id="pageSubTitle">E-1: Overview <SPAN id="pageNumber">(6 of 13)</SPAN></H3> <OL class="alphaLC" start="7"> <LI> <p class="outputTextNB"> <strong>Participant-Directed Services. </strong> <label id="svapdxE1_6:lbldtPDServices" for="svapdxE1_6:dtPDServices" class="outputLabel"> <span id="svapdxE1_6:lbltxt_dtPDServices" class="outputTextNB">Specify the participant direction opportunity (or opportunities) available for each waiver service that is specified as participant-directed in Appendix C-1/C-3.</span></label> </p> <table id="svapdxE1_6:dtPDServices" class="ckboxTable" border="1" cellpadding="2" cellspacing="0" summary="dynamic table for participant-directed services" ><thead ><tr ><th scope="col" ><span class="outputText">Waiver Service</span></th><th scope="col" ><span class="outputText">Employer Authority</span></th><th scope="col" ><span class="outputText">Budget Authority</span></th></tr> </thead><tbody > <tr ><td class="lft" ><input id="svapdxE1_6:dtPDServices:0:rowID" type="text" name="svapdxE1_6:dtPDServices:0:rowID" value="212286" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxE1_6:dtPDServices:0:text1" class="outputText">Independent Support Broker</span></td> <td class="ctr" ><input id="svapdxE1_6:dtPDServices:0:svcEmpAuth" type="checkbox" name="svapdxE1_6:dtPDServices:0:svcEmpAuth" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /></td> <td class="ctr" ><input id="svapdxE1_6:dtPDServices:0:svcBudAuth" type="checkbox" name="svapdxE1_6:dtPDServices:0:svcBudAuth" class="selectBooleanCheckbox" disabled="disabled" /></td> </tr> </tbody> </table> </LI> </OL> <H2 id="pageTitle">Appendix E: Participant Direction of Services</H2> <H3 id="pageSubTitle">E-1: Overview <SPAN id="pageNumber">(7 of 13)</SPAN></H3> <OL class="alphaLC" start="8"> <LI> <p class="outputTextNB"> <strong>Financial Management Services.</strong> Except in certain circumstances, financial management services are mandatory and integral to participant direction. A governmental entity and/or another third-party entity must perform necessary financial transactions on behalf of the waiver participant. <em>Select one</em>: </p> <div class="checkboxGroup"> <label><input id="svapdxE1_7:dosFMSIncl:0" type="radio" name="svapdxE1_7:dosFMSIncl" checked="checked" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;Yes. Financial Management Services are furnished through a third party entity.</label> <span class="outputTextNB"> <em>(Complete item E-1-i)</em>.</span> </div> <div class="firstIndent"> <!-- rendered="#{(varFactory.dosFMSIncl == '0') ? true : false}"> --> <p class="outputTextNB">Specify whether governmental and/or private entities furnish these services. <em>Check each that applies</em>:</p> <div class="checkboxGroup"> <input id="svapdxE1_7:dosFMSByGovEnt" type="checkbox" name="svapdxE1_7:dosFMSByGovEnt" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxE1_7:lbldosFMSByGovEnt" for="svapdxE1_7:dosFMSByGovEnt" class="outputLabel"> <span id="svapdxE1_7:lbltxt_dosFMSByGovEnt" class="outputText">Governmental entities</span></label> </div> <div class="checkboxGroup"> <input id="svapdxE1_7:dosFMSByPrivEnt" type="checkbox" name="svapdxE1_7:dosFMSByPrivEnt" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxE1_7:lbldosFMSByPrivEnt" for="svapdxE1_7:dosFMSByPrivEnt" class="outputLabel"> <span id="svapdxE1_7:lbltxt_dosFMSByPrivEnt" class="outputText">Private entities</span></label> </div> </div> <div class="checkboxGroup"> <label><input id="svapdxE1_7:dosFMSIncl:1" type="radio" name="svapdxE1_7:dosFMSIncl" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;No. Financial Management Services are not furnished. Standard Medicaid payment mechanisms are used.</label> <span class="outputTextNB"> <em>Do not complete Item E-1-i.</em></span> </div> <div class="noShow"><label><input id="svapdxE1_7:dosFMSIncl:2" type="radio" name="svapdxE1_7:dosFMSIncl" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </LI> </OL> <H2 id="pageTitle">Appendix E: Participant Direction of Services</H2> <H3 id="pageSubTitle">E-1: Overview <SPAN id="pageNumber">(8 of 13)</SPAN></H3> <OL class="alphaLC" start="9"> <LI> <p class="outputTextNB"> <strong>Provision of Financial Management Services.</strong> Financial management services (FMS) may be furnished as a waiver service or as an administrative activity. <em>Select one</em>: </p> <div class="checkboxGroup"><label><input id="svapdxE1_8:dosFMSType:0" type="radio" name="svapdxE1_8:dosFMSType" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;FMS are covered as the waiver service specified in Appendix C-1/C-3</label></div> <div class="firstIndent"> <p></p> <label id="svapdxE1_8:lblprintDosFMSSvc" for="svapdxE1_8:printDosFMSSvc" class="outputLabel"> <span id="svapdxE1_8:lbltxt_printDosFMSSvc" class="outputText">The waiver service entitled:</span></label><span id="svapdxE1_8:panel_print_dosFMSSvc"><textarea id="svapdxE1_8:printDosFMSSvc" name="svapdxE1_8:printDosFMSSvc" class="inputTextarea" readonly="readonly"></textarea></span> </div> <div class="checkboxGroup"><label><input id="svapdxE1_8:dosFMSType:1" type="radio" name="svapdxE1_8:dosFMSType" checked="checked" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;FMS are provided as an administrative activity.</label></div> <div class="noShow"><label><input id="svapdxE1_8:dosFMSType:2" type="radio" name="svapdxE1_8:dosFMSType" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> <div class="pph"> <!-- rendered="#{(varFactory.dosFMSType == '1') ? true : false}"> --> <p class="outputText">Provide the following information</p> <OL class="romanLC" start="1"> <li><p class="outputTextNB"> <strong>Types of Entities: </strong> <label id="svapdxE1_8:lbldosFMSAdmEnt" for="svapdxE1_8:dosFMSAdmEnt" class="outputLabel"> <span id="svapdxE1_8:lbltxt_dosFMSAdmEnt" class="outputTextNB">Specify the types of entities that furnish FMS and the method of procuring these services:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxE1_8:dosFMSAdmEntChrCntLbl" for="svapdxE1_8:dosFMSAdmEntChrCnt" class="outputLabel"> <span id="svapdxE1_8:dosFMSAdmEntChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxE1_8:dosFMSAdmEntChrCnt" type="text" name="svapdxE1_8:dosFMSAdmEntChrCnt" class="chrCnt" size="6" /><span id="svapdxE1_8:dosFMSAdmEntChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxE1_8:panel_dosFMSAdmEnt"><textarea id="svapdxE1_8:dosFMSAdmEnt" name="svapdxE1_8:dosFMSAdmEnt" class="inputTextarea25" onkeyup="Count(this);" readonly="readonly">The fiscal intermediary services were procured through a competitive bid process</textarea></span> </div> </li> <li><p class="outputTextNB"> <strong>Payment for FMS. </strong> <label id="svapdxE1_8:lbldosFMSAdmComp" for="svapdxE1_8:dosFMSAdmComp" class="outputLabel"> <span id="svapdxE1_8:lbltxt_dosFMSAdmComp" class="outputTextNB">Specify how FMS entities are compensated for the administrative activities that they perform:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxE1_8:dosFMSAdmCompChrCntLbl" for="svapdxE1_8:dosFMSAdmCompChrCnt" class="outputLabel"> <span id="svapdxE1_8:dosFMSAdmCompChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxE1_8:dosFMSAdmCompChrCnt" type="text" name="svapdxE1_8:dosFMSAdmCompChrCnt" class="chrCnt" size="6" /><span id="svapdxE1_8:dosFMSAdmCompChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxE1_8:panel_dosFMSAdmComp"><textarea id="svapdxE1_8:dosFMSAdmComp" name="svapdxE1_8:dosFMSAdmComp" class="inputTextarea25" onkeyup="Count(this);" readonly="readonly">Payment for the Independent Support Broker Service is made via direct vendor contract with the fiscal intermediary. The contractor is the same vendor that is used for the Elder and ABI waivers. The contract payment allocation takes into consideration the number of participants and the number of staff required to support activities to meet required deadlines. Cost is determined by the number of FTE's required to perform the functions. The payment is made quarterly. A separate contract will be executed for the CFC portion of the FI's responsibilities and costs will be allocated to each contract to prevent duplicative costs.</textarea></span> </div> </li> <li><p class="outputTextNB"> <strong>Scope of FMS.</strong> Specify the scope of the supports that FMS entities provide <em>(check each that applies)</em>: </p> <div class="firstIndent"> <p class="outputTextNB underline">Supports furnished when the participant is the employer of direct support workers:</p> <div class="checkboxGroup"> <input id="svapdxE1_8:dosFMSAdmEmpCitz" type="checkbox" name="svapdxE1_8:dosFMSAdmEmpCitz" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxE1_8:lbldosFMSAdmEmpCitz" for="svapdxE1_8:dosFMSAdmEmpCitz" class="outputLabel"> <span id="svapdxE1_8:lbltxt_dosFMSAdmEmpCitz" class="outputText">Assist participant in verifying support worker citizenship status</span></label> </div> <div class="checkboxGroup"> <input id="svapdxE1_8:dosFMSAdmEmpTime" type="checkbox" name="svapdxE1_8:dosFMSAdmEmpTime" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxE1_8:lbldosFMSAdmEmpTime" for="svapdxE1_8:dosFMSAdmEmpTime" class="outputLabel"> <span id="svapdxE1_8:lbltxt_dosFMSAdmEmpTime" class="outputText">Collect and process timesheets of support workers</span></label> </div> <div class="checkboxGroup"> <input id="svapdxE1_8:dosFMSAdmEmpPay" type="checkbox" name="svapdxE1_8:dosFMSAdmEmpPay" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxE1_8:lbldosFMSAdmEmpPay" for="svapdxE1_8:dosFMSAdmEmpPay" class="outputLabel"> <span id="svapdxE1_8:lbltxt_dosFMSAdmEmpPay" class="outputText">Process payroll, withholding, filing and payment of applicable federal, state and local employment-related taxes and insurance</span></label> </div> <div class="checkboxGroup"> <input id="svapdxE1_8:dosFMSAdmEmpOth" type="checkbox" name="svapdxE1_8:dosFMSAdmEmpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxE1_8:lbldosFMSAdmEmpOth" for="svapdxE1_8:dosFMSAdmEmpOth" class="outputLabel"> <span id="svapdxE1_8:lbltxt_dosFMSAdmEmpOth" class="outputText">Other </span></label> </div> <div class="firstIndent"> <!-- rendered="#{(varFactory.dosFMSAdmEmpOth) ? true : false}"> --> <p class="outputTextNB"> <label id="svapdxE1_8:lbldosFMSAdmEmpOthDscr" for="svapdxE1_8:dosFMSAdmEmpOthDscr" class="outputLabel"> <span id="svapdxE1_8:lbltxt_dosFMSAdmEmpOthDscr" class="outputTextNB em">Specify:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxE1_8:dosFMSAdmEmpOthDscrChrCntLbl" for="svapdxE1_8:dosFMSAdmEmpOthDscrChrCnt" class="outputLabel"> <span id="svapdxE1_8:dosFMSAdmEmpOthDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxE1_8:dosFMSAdmEmpOthDscrChrCnt" type="text" name="svapdxE1_8:dosFMSAdmEmpOthDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxE1_8:dosFMSAdmEmpOthDscrChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxE1_8:panel_dosFMSAdmEmpOthDscr"><textarea id="svapdxE1_8:dosFMSAdmEmpOthDscr" name="svapdxE1_8:dosFMSAdmEmpOthDscr" class="inputTextarea25" onkeyup="Count(this);" readonly="readonly">Provide consumer training that includes but is not limited to advertising/recruiting, interviewing techniques, employee training, ongoing performance evaluations of employees and problem solving or termination of employees. The training shall also include monitoring the quality of the plan implementation.</textarea></span> </div> </div> </div> <div class="firstIndent"> <p class="outputTextNB underline">Supports furnished when the participant exercises budget authority:</p> <div class="checkboxGroup"> <input id="svapdxE1_8:dosFMSAdmBudSepAcct" type="checkbox" name="svapdxE1_8:dosFMSAdmBudSepAcct" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxE1_8:lbldosFMSAdmBudSepAcct" for="svapdxE1_8:dosFMSAdmBudSepAcct" class="outputLabel"> <span id="svapdxE1_8:lbltxt_dosFMSAdmBudSepAcct" class="outputText">Maintain a separate account for each participant's participant-directed budget</span></label> </div> <div class="checkboxGroup"> <input id="svapdxE1_8:dosFMSAdmBudTrkFnds" type="checkbox" name="svapdxE1_8:dosFMSAdmBudTrkFnds" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxE1_8:lbldosFMSAdmBudTrkFnds" for="svapdxE1_8:dosFMSAdmBudTrkFnds" class="outputLabel"> <span id="svapdxE1_8:lbltxt_dosFMSAdmBudTrkFnds" class="outputText">Track and report participant funds, disbursements and the balance of participant funds</span></label> </div> <div class="checkboxGroup"> <input id="svapdxE1_8:dosFMSAdmBudGdsSvc" type="checkbox" name="svapdxE1_8:dosFMSAdmBudGdsSvc" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxE1_8:lbldosFMSAdmBudGdsSvc" for="svapdxE1_8:dosFMSAdmBudGdsSvc" class="outputLabel"> <span id="svapdxE1_8:lbltxt_dosFMSAdmBudGdsSvc" class="outputText">Process and pay invoices for goods and services approved in the service plan</span></label> </div> <div class="checkboxGroup"> <input id="svapdxE1_8:dosFMSAdmBudRptg" type="checkbox" name="svapdxE1_8:dosFMSAdmBudRptg" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxE1_8:lbldosFMSAdmBudRptg" for="svapdxE1_8:dosFMSAdmBudRptg" class="outputLabel"> <span id="svapdxE1_8:lbltxt_dosFMSAdmBudRptg" class="outputText">Provide participant with periodic reports of expenditures and the status of the participant-directed budget</span></label> </div> <div class="checkboxGroup"> <input id="svapdxE1_8:dosFMSAdmBudOth" type="checkbox" name="svapdxE1_8:dosFMSAdmBudOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxE1_8:lbldosFMSAdmBudOth" for="svapdxE1_8:dosFMSAdmBudOth" class="outputLabel"> <span id="svapdxE1_8:lbltxt_dosFMSAdmBudOth" class="outputText">Other services and supports</span></label> </div> <div class="firstIndent"> <!-- rendered="#{(varFactory.dosFMSAdmBudOth) ? true : false}"> --> <p class="outputTextNB"> <label id="svapdxE1_8:lbldosFMSAdmBudOthDscr" for="svapdxE1_8:dosFMSAdmBudOthDscr" class="outputLabel"> <span id="svapdxE1_8:lbltxt_dosFMSAdmBudOthDscr" class="outputTextNB em">Specify:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxE1_8:dosFMSAdmBudOthDscrChrCntLbl" for="svapdxE1_8:dosFMSAdmBudOthDscrChrCnt" class="outputLabel"> <span id="svapdxE1_8:dosFMSAdmBudOthDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxE1_8:dosFMSAdmBudOthDscrChrCnt" type="text" name="svapdxE1_8:dosFMSAdmBudOthDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxE1_8:dosFMSAdmBudOthDscrChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxE1_8:panel_dosFMSAdmBudOthDscr"><textarea id="svapdxE1_8:dosFMSAdmBudOthDscr" name="svapdxE1_8:dosFMSAdmBudOthDscr" class="inputTextarea25" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> </div> <div class="firstIndent"> <p class="outputTextNB underline">Additional functions/activities:</p> <div class="checkboxGroup"> <input id="svapdxE1_8:dosFMSAdmMedAgmt" type="checkbox" name="svapdxE1_8:dosFMSAdmMedAgmt" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxE1_8:lbldosFMSAdmMedAgmt" for="svapdxE1_8:dosFMSAdmMedAgmt" class="outputLabel"> <span id="svapdxE1_8:lbltxt_dosFMSAdmMedAgmt" class="outputText">Execute and hold Medicaid provider agreements as authorized under a written agreement with the Medicaid agency</span></label> </div> <div class="checkboxGroup"> <input id="svapdxE1_8:dosFMSAdmMgFnds" type="checkbox" name="svapdxE1_8:dosFMSAdmMgFnds" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxE1_8:lbldosFMSAdmMgFnds" for="svapdxE1_8:dosFMSAdmMgFnds" class="outputLabel"> <span id="svapdxE1_8:lbltxt_dosFMSAdmMgFnds" class="outputText">Receive and disburse funds for the payment of participant-directed services under an agreement with the Medicaid agency or operating agency</span></label> </div> <div class="checkboxGroup"> <input id="svapdxE1_8:dosFMSAdmRpt" type="checkbox" name="svapdxE1_8:dosFMSAdmRpt" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxE1_8:lbldosFMSAdmRpt" for="svapdxE1_8:dosFMSAdmRpt" class="outputLabel"> <span id="svapdxE1_8:lbltxt_dosFMSAdmRpt" class="outputText">Provide other entities specified by the State with periodic reports of expenditures and the status of the participant-directed budget</span></label> </div> <div class="checkboxGroup"> <input id="svapdxE1_8:dosFMSAdmOth" type="checkbox" name="svapdxE1_8:dosFMSAdmOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxE1_8:lbldosFMSAdmOth" for="svapdxE1_8:dosFMSAdmOth" class="outputLabel"> <span id="svapdxE1_8:lbltxt_dosFMSAdmOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <!-- rendered="#{(varFactory.dosFMSAdmOth) ? true : false}"> --> <p class="outputTextNB"> <label id="svapdxE1_8:lbldosFMSAdmOthDscr" for="svapdxE1_8:dosFMSAdmOthDscr" class="outputLabel"> <span id="svapdxE1_8:lbltxt_dosFMSAdmOthDscr" class="outputTextNB em">Specify:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxE1_8:dosFMSAdmOthDscrChrCntLbl" for="svapdxE1_8:dosFMSAdmOthDscrChrCnt" class="outputLabel"> <span id="svapdxE1_8:dosFMSAdmOthDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxE1_8:dosFMSAdmOthDscrChrCnt" type="text" name="svapdxE1_8:dosFMSAdmOthDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxE1_8:dosFMSAdmOthDscrChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxE1_8:panel_dosFMSAdmOthDscr"><textarea id="svapdxE1_8:dosFMSAdmOthDscr" name="svapdxE1_8:dosFMSAdmOthDscr" class="inputTextarea25" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> </div> </li> <li><p class="outputTextNB"> <strong>Oversight of FMS Entities. </strong> <label id="svapdxE1_8:lbldosFMSAdmEntOvrst" for="svapdxE1_8:dosFMSAdmEntOvrst" class="outputLabel"> <span id="svapdxE1_8:lbltxt_dosFMSAdmEntOvrst" class="outputTextNB">Specify the methods that are employed to: (a) monitor and assess the performance of FMS entities, including ensuring the integrity of the financial transactions that they perform; (b) the entity (or entities) responsible for this monitoring; and, (c) how frequently performance is assessed.</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxE1_8:dosFMSAdmEntOvrstChrCntLbl" for="svapdxE1_8:dosFMSAdmEntOvrstChrCnt" class="outputLabel"> <span id="svapdxE1_8:dosFMSAdmEntOvrstChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxE1_8:dosFMSAdmEntOvrstChrCnt" type="text" name="svapdxE1_8:dosFMSAdmEntOvrstChrCnt" class="chrCnt" size="6" /><span id="svapdxE1_8:dosFMSAdmEntOvrstChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxE1_8:panel_dosFMSAdmEntOvrst"><textarea id="svapdxE1_8:dosFMSAdmEntOvrst" name="svapdxE1_8:dosFMSAdmEntOvrst" class="inputTextarea25" onkeyup="Count(this);" readonly="readonly">DSS is responsible to monitor and assess the performance of the fiscal intermediary by the following methods. - Review of quarterly and ad hoc reports from the fiscal intermediary -• Annual on-site visits to review operational and administrative functions - Ongoing correspondence between the fiscal intermediary and DSS staff regarding progress on deliverables. (e.g. claims processing) - Random audits of Medicaid Providers by DSS Quality Assurance Division - Biweekly conference calls with the fiscal intermediary to discuss ongoing operations, and review billing issues as well as issues with the consumers and PCAs.</textarea></span> </div> </li> </OL> </div> </LI> </OL> <H2 id="pageTitle">Appendix E: Participant Direction of Services</H2> <H3 id="pageSubTitle">E-1: Overview <SPAN id="pageNumber">(9 of 13)</SPAN></H3> <OL class="alphaLC" start="10"> <LI> <p class="outputTextNB"> <strong>Information and Assistance in Support of Participant Direction.</strong> In addition to financial management services, participant direction is facilitated when information and assistance are available to support participants in managing their services. These supports may be furnished by one or more entities, provided that there is no duplication. Specify the payment authority (or authorities) under which these supports are furnished and, where required, provide the additional information requested <em>(check each that applies)</em>: </p> <div class="checkboxGroup"> <input id="svapdxE1_9:dosInfoCsMgmt" type="checkbox" name="svapdxE1_9:dosInfoCsMgmt" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxE1_9:lbldosInfoCsMgmt" for="svapdxE1_9:dosInfoCsMgmt" class="outputLabel"> <span id="svapdxE1_9:lbltxt_dosInfoCsMgmt1" class="outputText">Case Management Activity. </span><span id="svapdxE1_9:lbltxt_dosInfoCsMgmt2" class="outputTextNB">Information and assistance in support of participant direction are furnished as an element of Medicaid case management services.</span></label> </div> <div class="firstIndent"> <!-- rendered="#{(varFactory.dosInfoCsMgmt) ? true : false}"> --> <p> <label id="svapdxE1_9:lbldosInfoCsMgmtDscr" for="svapdxE1_9:dosInfoCsMgmtDscr" class="outputLabel"> <span id="svapdxE1_9:lbltxt_dosInfoCsMgmtDscr" class="outputTextNB em">Specify in detail the information and assistance that are furnished through case management for each participant direction opportunity under the waiver:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxE1_9:dosInfoCsMgmtDscrChrCntLbl" for="svapdxE1_9:dosInfoCsMgmtDscrChrCnt" class="outputLabel"> <span id="svapdxE1_9:dosInfoCsMgmtDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxE1_9:dosInfoCsMgmtDscrChrCnt" type="text" name="svapdxE1_9:dosInfoCsMgmtDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxE1_9:dosInfoCsMgmtDscrChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxE1_9:panel_dosInfoCsMgmtDscr"><textarea id="svapdxE1_9:dosInfoCsMgmtDscr" name="svapdxE1_9:dosInfoCsMgmtDscr" class="inputTextarea25" onkeyup="Count(this);" readonly="readonly">The Care Manager is responsible to complete the comprehensive assessment and develops the Total Plan of Care in collaboration with the participant and his or her representative if desired by the client. As part of the explanation of services options, self services are explained as options depending on the client's identified needs. Care Managers will explain the differences between common law employer option available under the CFC. Care managers will also facilitate referrals to either the Fiscal Intermediary or an agency for these participant directed service options. This function is considered to be part of the required functions of care management and is included in the daily reimbursement rate. The care manager is not responsible for assisting the client with the hiring, training, supervision and firing component of self direction. That role is specific to the Independent Support Broker</textarea></span> </div> </div> <div class="checkboxGroup"> <input id="svapdxE1_9:dosInfoSvc" type="checkbox" name="svapdxE1_9:dosInfoSvc" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxE1_9:lbldosInfoSvc" for="svapdxE1_9:dosInfoSvc" class="outputLabel"> <span id="svapdxE1_9:lbltxt_dosInfoSvc1" class="outputText">Waiver Service Coverage. </span></label><label id="svapdxE1_9:lbldosInfoSvcName" for="svapdxE1_9:dtPDInfoServices" class="outputLabel"> <span id="svapdxE1_9:lbltxt_dosInfoSvcName" class="outputTextNB">Information and assistance in support of participant direction are provided through the following waiver service coverage(s) specified in Appendix C-1/C-3 (check each that applies):</span></label><table id="svapdxE1_9:dtPDInfoServices" class="ckboxTable" border="1" cellpadding="2" cellspacing="0" summary="dynamic table for participant-directed services" ><thead ><tr ><th scope="col" ><span class="outputText">Participant-Directed Waiver Service</span></th><th scope="col" ><span class="outputText">Information and Assistance Provided through this Waiver Service Coverage</span></th></tr> </thead><tbody > <tr ><td class="lft" ><input id="svapdxE1_9:dtPDInfoServices:0:rowID" type="text" name="svapdxE1_9:dtPDInfoServices:0:rowID" value="200881" class="noShow" disabled="disabled" readonly="readonly" /><span id="svapdxE1_9:dtPDInfoServices:0:serviceName" class="outputText">Adult Family Living/Foster Care</span></td> <td class="ctr" ><input id="svapdxE1_9:dtPDInfoServices:0:svcInfoAsst" type="checkbox" name="svapdxE1_9:dtPDInfoServices:0:svcInfoAsst" class="selectBooleanCheckbox" disabled="disabled" /></td> </tr> <tr ><td class="lft" ><input id="svapdxE1_9:dtPDInfoServices:1:rowID" type="text" name="svapdxE1_9:dtPDInfoServices:1:rowID" value="220784" class="noShow" disabled="disabled" readonly="readonly" /><span id="svapdxE1_9:dtPDInfoServices:1:serviceName" class="outputText">Care Management</span></td> <td class="ctr" ><input id="svapdxE1_9:dtPDInfoServices:1:svcInfoAsst" type="checkbox" name="svapdxE1_9:dtPDInfoServices:1:svcInfoAsst" class="selectBooleanCheckbox" disabled="disabled" /></td> </tr> <tr ><td class="lft" ><input id="svapdxE1_9:dtPDInfoServices:2:rowID" type="text" name="svapdxE1_9:dtPDInfoServices:2:rowID" value="212286" class="noShow" disabled="disabled" readonly="readonly" /><span id="svapdxE1_9:dtPDInfoServices:2:serviceName" class="outputText">Independent Support Broker</span></td> <td class="ctr" ><input id="svapdxE1_9:dtPDInfoServices:2:svcInfoAsst" type="checkbox" name="svapdxE1_9:dtPDInfoServices:2:svcInfoAsst" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /></td> </tr> </tbody> </table> </div> <div class="checkboxGroup"> <input id="svapdxE1_9:dosInfoAdm" type="checkbox" name="svapdxE1_9:dosInfoAdm" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxE1_9:lbldosInfoAdm" for="svapdxE1_9:dosInfoAdm" class="outputLabel"> <span id="svapdxE1_9:lbltxt_dosInfoAdm1" class="outputText">Administrative Activity. </span><span id="svapdxE1_9:lbltxt_dosInfoAdm2" class="outputTextNB">Information and assistance in support of participant direction are furnished as an administrative activity.</span></label> </div> <div class="firstIndent"> <!-- rendered="#{(varFactory.dosInfoAdm) ? true : false}"> --> <p class="outputTextNB"> <label id="svapdxE1_9:lbldosInfoAdmDscr" for="svapdxE1_9:dosInfoAdmDscr" class="outputLabel"> <span id="svapdxE1_9:lbltxt_dosInfoAdmDscr" class="outputTextNB em">Specify (a) the types of entities that furnish these supports; (b) how the supports are procured and compensated; (c) describe in detail the supports that are furnished for each participant direction opportunity under the waiver; (d) the methods and frequency of assessing the performance of the entities that furnish these supports; and, (e) the entity or entities responsible for assessing performance:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxE1_9:dosInfoAdmDscrChrCntLbl" for="svapdxE1_9:dosInfoAdmDscrChrCnt" class="outputLabel"> <span id="svapdxE1_9:dosInfoAdmDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxE1_9:dosInfoAdmDscrChrCnt" type="text" name="svapdxE1_9:dosInfoAdmDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxE1_9:dosInfoAdmDscrChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxE1_9:panel_dosInfoAdmDscr"><textarea id="svapdxE1_9:dosInfoAdmDscr" name="svapdxE1_9:dosInfoAdmDscr" class="inputTextarea25" onkeyup="Count(this);" readonly="readonly">The Access Agency care manager, the HCBS Unit and the contracted fiscal intermediary are responsible for the oversight and support of participant self-direction: All waiver participants receive this service through their care manager: The Access Agency care manager, who acts on behalf of the Medicaid Agency, will be the assessor and developer of the service plan. He/she must have a thorough knowledge of all services available through this waiver, as well as all the services and supports available through the regular State Medicaid program, and from all other state and federal funding. Sources of informal support are often the crucial determining factor if the waiver participant is to successfully remain in the community. Additionally, the care manager is responsible to inform and explain to the consumer that this is a self directed program. Care Manager Responsibilities/ Functions: - The care manager assists the consumers with the selection of service and work duties for employees if requested. - Maintain availability to address and reported level of care changes - Support at the request of the participant any intervention necessary with the fiscal intermediary or community provider on issues related to program administration. DSS also contracts with a fiduciary to support the self direction of consumers for the PCA waiver. - The fiscal intermediary supports are procured and compensated through competitively bid contracts. - After assessment by the care manager, and approval for waiver services, the fiscal intermediary would explain the program as self directed and client centered. The consumer is trained that they are the employers who will hire, train and manage their own employees. - The fiscal intermediary acts as the conduit to the Department of Labor and the Federal government training the employer to complete the necessary paperwork to enable them to hire employees of their selection. - The consumer is trained how to complete the time sheets and when to submit them to the fiscal intermediary for payment. - The fiscal intermediary has a registry of providers of Independent support Broker Service that is made available to the consumer to help and allow them to hire an employee of their choice. The fiscal intermediary is responsible to provide the Department with quarterly reports indicating the frequency in which the above services were provided. Additionally they must provide to the department the results of an annual consumer satisfaction survey.</textarea></span> </div> </div> </LI> </OL> <H2 id="pageTitle">Appendix E: Participant Direction of Services</H2> <H3 id="pageSubTitle">E-1: Overview <SPAN id="pageNumber">(10 of 13)</SPAN></H3> <OL class="alphaLC" start="11"> <LI> <p class="outputTextNB"> <strong>Independent Advocacy</strong> <em>(select one)</em>. </p> <table id="svapdxE1_10:dosIndAdvo" class="selectOneRadio"> <tr> <td> <input type="radio" name="svapdxE1_10:dosIndAdvo" id="svapdxE1_10:dosIndAdvo:0" value="0" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxE1_10:dosIndAdvo:0"> No. Arrangements have not been made for independent advocacy.</label></td> </tr> <tr> <td> <input type="radio" checked="checked" name="svapdxE1_10:dosIndAdvo" id="svapdxE1_10:dosIndAdvo:1" value="1" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxE1_10:dosIndAdvo:1"> Yes. Independent advocacy is available to participants who direct their services.</label></td> </tr> </table> <div class="firstIndent"> <!-- rendered="#{(varFactory.dosIndAdvo == 1) ? true : false}"> --> <p class="outputTextNB"> <label id="svapdxE1_10:lbl_dosIndAdvoDscr" for="svapdxE1_10:dosIndAdvoDscr" class="outputLabel"> <span id="svapdxE1_10:lbltxt_dosIndAdvoDscr" class="outputTextNB em">Describe the nature of this independent advocacy and how participants may access this advocacy:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxE1_10:dosIndAdvoDscrChrCntLbl" for="svapdxE1_10:dosIndAdvoDscrChrCnt" class="outputLabel"> <span id="svapdxE1_10:dosIndAdvoDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxE1_10:dosIndAdvoDscrChrCnt" type="text" name="svapdxE1_10:dosIndAdvoDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxE1_10:dosIndAdvoDscrChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxE1_10:panel_dosIndAdvoDscr"><textarea id="svapdxE1_10:dosIndAdvoDscr" name="svapdxE1_10:dosIndAdvoDscr" class="inputTextareaLong" onkeyup="Count(this);" readonly="readonly">Connecticut's Office of Protection and Advocacy (P&amp;A) provides supports and advocacy for persons with disabilities. P &amp; A has a statewide toll-free number and a website. They have served as advocates for persons with disabilities receiving PCA services, and must be requested by the consumer. The staff at the Office of Protection and Advocacy does not direct PCA waiver services, perform assessments or have monitoring oversight or fiscal responsibilities.</textarea></span> </div> </div> </LI> </OL> <H2 id="pageTitle">Appendix E: Participant Direction of Services</H2> <H3 id="pageSubTitle">E-1: Overview <SPAN id="pageNumber">(11 of 13)</SPAN></H3> <OL class="alphaLC" start="12"> <LI> <p class="outputTextNB"> <strong>Voluntary Termination of Participant Direction.</strong> <label id="svapdxE1_11:lbl_dosVolTermAccm" for="svapdxE1_11:dosVolTermAccm" class="outputLabel"> <span id="svapdxE1_11:lbltxt_dosVolTermAccm" class="outputTextNB">Describe how the State accommodates a participant who voluntarily terminates participant direction in order to receive services through an alternate service delivery method, including how the State assures continuity of services and participant health and welfare during the transition from participant direction:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxE1_11:dosVolTermAccmChrCntLbl" for="svapdxE1_11:dosVolTermAccmChrCnt" class="outputLabel"> <span id="svapdxE1_11:dosVolTermAccmChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxE1_11:dosVolTermAccmChrCnt" type="text" name="svapdxE1_11:dosVolTermAccmChrCnt" class="chrCnt" size="6" /><span id="svapdxE1_11:dosVolTermAccmChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxE1_11:panel_dosVolTermAccm"><textarea id="svapdxE1_11:dosVolTermAccm" name="svapdxE1_11:dosVolTermAccm" class="inputTextareaLong" onkeyup="Count(this);" readonly="readonly">Participant direction of self directed Waiver services may be voluntarily terminated. Should a client opt not to self direct, or appoint someone to direct, they can withdraw from the Waiver. Home Health Services or other agency based services, through the Medicaid program replaces services for clients who do not wish to self-direct. Independent support Broker is available both as a self directed and a waiver service. If a participant chooses to terminate self-direction, the care manager aids in the identification of agency provider and informal supports to accommodate the consumer's need.</textarea></span> </div> </LI> </OL> <H2 id="pageTitle">Appendix E: Participant Direction of Services</H2> <H3 id="pageSubTitle">E-1: Overview <SPAN id="pageNumber">(12 of 13)</SPAN></H3> <OL class="alphaLC" start="13"> <LI> <p class="outputTextNB"> <strong>Involuntary Termination of Participant Direction.</strong> <label id="svapdxE1_12:lbl_dosInvolTermDscr" for="svapdxE1_12:dosInvolTermDscr" class="outputLabel"> <span id="svapdxE1_12:lbltxt_dosInvolTermDscr" class="outputTextNB">Specify the circumstances when the State will involuntarily terminate the use of participant direction and require the participant to receive provider-managed services instead, including how continuity of services and participant health and welfare is assured during the transition.</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxE1_12:dosInvolTermDscrChrCntLbl" for="svapdxE1_12:dosInvolTermDscrChrCnt" class="outputLabel"> <span id="svapdxE1_12:dosInvolTermDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxE1_12:dosInvolTermDscrChrCnt" type="text" name="svapdxE1_12:dosInvolTermDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxE1_12:dosInvolTermDscrChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxE1_12:panel_dosInvolTermDscr"><textarea id="svapdxE1_12:dosInvolTermDscr" name="svapdxE1_12:dosInvolTermDscr" class="inputTextareaLong" onkeyup="Count(this);" readonly="readonly">Participant direction of self-directed waiver services can be involuntarily terminated, when a consumer does not demonstrate the ability to manage their own Independent Support Broker, and will not appoint a representative. In this circumstance an agency based provider would be offered as an alternative.</textarea></span> </div> </LI> </OL> <H2 id="pageTitle">Appendix E: Participant Direction of Services</H2> <H3 id="pageSubTitle">E-1: Overview <SPAN id="pageNumber">(13 of 13)</SPAN></H3> <OL class="alphaLC" start="14"> <LI> <p class="outputTextNB"><strong>Goals for Participant Direction.</strong> In the following table, provide the State's goals for each year that the waiver is in effect for the unduplicated number of waiver participants who are expected to elect each applicable participant direction opportunity. Annually, the State will report to CMS the number of participants who elect to direct their waiver services. </p> <table border="1" cellpadding="1" cellspacing="0" class="ckboxTable"> <caption>Table E-1-n</caption> <thead> <tr> <th></th> <th id="EA">Employer Authority Only</th> <th id="BA">Budget Authority Only or Budget Authority in Combination with Employer Authority</th> </tr> <tr> <th id="WY">Waiver Year</th> <th id="EANP">Number of Participants</th> <th id="BANP">Number of Participants</th> </tr> </thead> <tbody> <tr> <td headers="WY">Year 1</td> <td headers="EA EANP"> <input id="svapdxE1_13:dosGlsEmpYr1Qty" type="text" name="svapdxE1_13:dosGlsEmpYr1Qty" value="900" class="inputText" readonly="readonly" /> </td> <td headers="BA BANP"> <input id="svapdxE1_13:dosGlsBudYr1Qty" type="text" name="svapdxE1_13:dosGlsBudYr1Qty" class="inputText" readonly="readonly" /> </td> </tr> <tr> <td headers="WY">Year 2</td> <td headers="EA EANP"> <input id="svapdxE1_13:dosGlsEmpYr2Qty" type="text" name="svapdxE1_13:dosGlsEmpYr2Qty" value="910" class="inputText" readonly="readonly" /> </td> <td headers="BA BANP"> <input id="svapdxE1_13:dosGlsBudYr2Qty" type="text" name="svapdxE1_13:dosGlsBudYr2Qty" class="inputText" readonly="readonly" /> </td> </tr> <tr> <td headers="WY">Year 3</td> <td headers="EA EANP"> <input id="svapdxE1_13:dosGlsEmpYr3Qty" type="text" name="svapdxE1_13:dosGlsEmpYr3Qty" value="920" class="inputText" readonly="readonly" /> </td> <td headers="BA BANP"> <input id="svapdxE1_13:dosGlsBudYr3Qty" type="text" name="svapdxE1_13:dosGlsBudYr3Qty" class="inputText" readonly="readonly" /> </td> </tr> <tr> <td headers="WY">Year 4</td> <td headers="EA EANP"> <input id="svapdxE1_13:dosGlsEmpYr4Qty" type="text" name="svapdxE1_13:dosGlsEmpYr4Qty" value="930" class="inputText" readonly="readonly" /> </td> <td headers="BA BANP"> <input id="svapdxE1_13:dosGlsBudYr4Qty" type="text" name="svapdxE1_13:dosGlsBudYr4Qty" class="inputText" readonly="readonly" /> </td> </tr> <tr> <td headers="WY">Year 5</td> <td headers="EA EANP"> <input id="svapdxE1_13:dosGlsEmpYr5Qty" type="text" name="svapdxE1_13:dosGlsEmpYr5Qty" value="950" class="inputText" readonly="readonly" /> </td> <td headers="BA BANP"> <input id="svapdxE1_13:dosGlsBudYr5Qty" type="text" name="svapdxE1_13:dosGlsBudYr5Qty" class="inputText" readonly="readonly" /> </td> </tr> </tbody> </table> </LI> </OL> <H2 id="pageTitle">Appendix E: Participant Direction of Services</H2> <H3 id="pageSubTitle">E-2: Opportunities for Participant Direction <SPAN id="pageNumber">(1 of 6)</SPAN></H3> <OL class="alphaLC" start="1"> <LI><P class="outputTextNB"><STRONG>Participant - Employer Authority</STRONG> <em>Complete when the waiver offers the employer authority opportunity as indicated in Item E-1-b:</em></P> <OL class="romanLC" start="1"> <LI><p class="outputTextNB"><strong>Participant Employer Status.</strong> Specify the participant's employer status under the waiver. <em>Select one or both</em>:</p> <div class="checkboxGroup"> <input id="svapdxE2_1:dosPtcEmpCoemp" type="checkbox" name="svapdxE2_1:dosPtcEmpCoemp" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxE2_1:lbldosPtcEmpCoemp" for="svapdxE2_1:dosPtcEmpCoemp" class="outputLabel"> <span id="svapdxE2_1:lbltxtdosPtcEmpCoemp1" class="outputText">Participant/Co-Employer. </span><span id="svapdxE2_1:lbltxtdosPtcEmpCoemp2" class="outputTextNB">The participant (or the participant's representative) functions as the co-employer (managing employer) of workers who provide waiver services. An agency is the common law employer of participant-selected/recruited staff and performs necessary payroll and human resources functions. Supports are available to assist the participant in conducting employer-related functions.</span></label> </div> <div class="firstIndent"> <!-- rendered="#{(varFactory.dosPtcEmpCoemp) ? true : false}"> --> <p> <label id="svapdxE2_1:lbldosPtcEmpCoempAg" for="svapdxE2_1:dosPtcEmpCoempAg" class="outputLabel"> <span id="svapdxE2_1:lbltxtdosPtcEmpCoempAg1" class="outputTextNB">Specify the types of agencies (a.k.a., agencies with choice) that serve as co-employers of participant-selected staff:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxE2_1:dosPtcEmpCoempAgChrCntLbl" for="svapdxE2_1:dosPtcEmpCoempAgChrCnt" class="outputLabel"> <span id="svapdxE2_1:dosPtcEmpCoempAgChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxE2_1:dosPtcEmpCoempAgChrCnt" type="text" name="svapdxE2_1:dosPtcEmpCoempAgChrCnt" class="chrCnt" size="6" /><span id="svapdxE2_1:dosPtcEmpCoempAgChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxE2_1:panel_dosPtcEmpCoempAg"><textarea id="svapdxE2_1:dosPtcEmpCoempAg" name="svapdxE2_1:dosPtcEmpCoempAg" class="inputTextarea25" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="checkboxGroup"> <input id="svapdxE2_1:dosPtcEmpComLaw" type="checkbox" name="svapdxE2_1:dosPtcEmpComLaw" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxE2_1:lbldosPtcEmpComLaw" for="svapdxE2_1:dosPtcEmpComLaw" class="outputLabel"> <span id="svapdxE2_1:lbltxtdosPtcEmpComLaw1" class="outputText">Participant/Common Law Employer. </span><span id="svapdxE2_1:lbltxtdosPtcEmpComLaw2" class="outputTextNB">The participant (or the participant's representative) is the common law employer of workers who provide waiver services. An IRS-approved Fiscal/Employer Agent functions as the participant's agent in performing payroll and other employer responsibilities that are required by federal and state law. Supports are available to assist the participant in conducting employer-related functions.</span></label> </div> </LI> <LI><p class="outputTextNB"><strong>Participant Decision Making Authority.</strong> The participant (or the participant's representative) has decision making authority over workers who provide waiver services. <em>Select one or more decision making authorities that participants exercise</em>:</p> <div class="checkboxGroup"> <input id="svapdxE2_1:dosStfRecrt" type="checkbox" name="svapdxE2_1:dosStfRecrt" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxE2_1:lbldosStfRecrt" for="svapdxE2_1:dosStfRecrt" class="outputLabel"> <span id="svapdxE2_1:lbltxtdosStfRecrt" class="outputText">Recruit staff</span></label> </div> <div class="checkboxGroup"> <input id="svapdxE2_1:dosStfRfrAgnc" type="checkbox" name="svapdxE2_1:dosStfRfrAgnc" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxE2_1:lbldosStfRfrAgnc" for="svapdxE2_1:dosStfRfrAgnc" class="outputLabel"> <span id="svapdxE2_1:lbltxtdosStfRfrAgnc" class="outputText">Refer staff to agency for hiring (co-employer)</span></label> </div> <div class="checkboxGroup"> <input id="svapdxE2_1:dosStfSel" type="checkbox" name="svapdxE2_1:dosStfSel" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxE2_1:lbldosStfSel" for="svapdxE2_1:dosStfSel" class="outputLabel"> <span id="svapdxE2_1:lbltxtdosStfSel" class="outputText">Select staff from worker registry</span></label> </div> <div class="checkboxGroup"> <input id="svapdxE2_1:dosStfHir" type="checkbox" name="svapdxE2_1:dosStfHir" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxE2_1:lbldosStfHir" for="svapdxE2_1:dosStfHir" class="outputLabel"> <span id="svapdxE2_1:lbltxtdosStfHir" class="outputText">Hire staff common law employer</span></label> </div> <div class="checkboxGroup"> <input id="svapdxE2_1:dosStfVerQual" type="checkbox" name="svapdxE2_1:dosStfVerQual" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxE2_1:lbldosStfVerQual" for="svapdxE2_1:dosStfVerQual" class="outputLabel"> <span id="svapdxE2_1:lbltxtdosStfVerQual" class="outputText">Verify staff qualifications</span></label> </div> <div class="checkboxGroup"> <input id="svapdxE2_1:dosStfBckChk" type="checkbox" name="svapdxE2_1:dosStfBckChk" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxE2_1:lbldosStfBckChk" for="svapdxE2_1:dosStfBckChk" class="outputLabel"> <span id="svapdxE2_1:lbltxtdosStfBckChk" class="outputText">Obtain criminal history and/or background investigation of staff</span></label> </div> <div class="firstIndent"> <!-- rendered="#{(varFactory.dosStfBckChk) ? true : false}"> --> <p> <label id="svapdxE2_1:lbldosStfBckChkComp" for="svapdxE2_1:dosStfBckChkComp" class="outputLabel"> <span id="svapdxE2_1:lbltxtdosStfBckChkComp" class="outputTextNB">Specify how the costs of such investigations are compensated:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxE2_1:dosStfBckChkCompChrCntLbl" for="svapdxE2_1:dosStfBckChkCompChrCnt" class="outputLabel"> <span id="svapdxE2_1:dosStfBckChkCompChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxE2_1:dosStfBckChkCompChrCnt" type="text" name="svapdxE2_1:dosStfBckChkCompChrCnt" class="chrCnt" size="6" /><span id="svapdxE2_1:dosStfBckChkCompChrCntMax" class="chrCnt"> out of 4000</span> </div> <div class="inputTextareaWA"> <span id="svapdxE2_1:panel_dosStfBckChkComp"><textarea id="svapdxE2_1:dosStfBckChkComp" name="svapdxE2_1:dosStfBckChkComp" class="inputTextarea" onkeyup="Count(this);" readonly="readonly">The fiscal intermediary, at no cost to the participant, performs this function. The results are forwarded to the waiver participant.</textarea></span> </div> </div> <div class="checkboxGroup"> <input id="svapdxE2_1:dosStfAddQual" type="checkbox" name="svapdxE2_1:dosStfAddQual" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxE2_1:lbldosStfAddQual" for="svapdxE2_1:dosStfAddQual" class="outputLabel"> <span id="svapdxE2_1:lbltxtdosStfAddQual" class="outputText">Specify additional staff qualifications based on participant needs and preferences so long as such qualifications are consistent with the qualifications specified in Appendix C-1/C-3.</span></label> </div> <div class="checkboxGroup"> <input id="svapdxE2_1:dosStfDut" type="checkbox" name="svapdxE2_1:dosStfDut" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxE2_1:lbldosStfDut" for="svapdxE2_1:dosStfDut" class="outputLabel"> <span id="svapdxE2_1:lbltxtdosStfDut" class="outputText">Determine staff duties consistent with the service specifications in Appendix C-1/C-3.</span></label> </div> <div class="checkboxGroup"> <input id="svapdxE2_1:dosStfWgBen" type="checkbox" name="svapdxE2_1:dosStfWgBen" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxE2_1:lbldosStfWgBen" for="svapdxE2_1:dosStfWgBen" class="outputLabel"> <span id="svapdxE2_1:lbltxtdosStfWgBen" class="outputText">Determine staff wages and benefits subject to State limits</span></label> </div> <div class="checkboxGroup"> <input id="svapdxE2_1:dosStfSch" type="checkbox" name="svapdxE2_1:dosStfSch" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxE2_1:lbldosStfSch" for="svapdxE2_1:dosStfSch" class="outputLabel"> <span id="svapdxE2_1:lbltxtdosStfSch" class="outputText">Schedule staff</span></label> </div> <div class="checkboxGroup"> <input id="svapdxE2_1:dosStfTrn" type="checkbox" name="svapdxE2_1:dosStfTrn" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxE2_1:lbldosStfTrn" for="svapdxE2_1:dosStfTrn" class="outputLabel"> <span id="svapdxE2_1:lbltxtdosStfTrn" class="outputText">Orient and instruct staff in duties</span></label> </div> <div class="checkboxGroup"> <input id="svapdxE2_1:dosStfSprv" type="checkbox" name="svapdxE2_1:dosStfSprv" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxE2_1:lbldosStfSprv" for="svapdxE2_1:dosStfSprv" class="outputLabel"> <span id="svapdxE2_1:lbltxtdosStfSprv" class="outputText">Supervise staff</span></label> </div> <div class="checkboxGroup"> <input id="svapdxE2_1:dosStfEval" type="checkbox" name="svapdxE2_1:dosStfEval" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxE2_1:lbldosStfEval" for="svapdxE2_1:dosStfEval" class="outputLabel"> <span id="svapdxE2_1:lbltxtdosStfEval" class="outputText">Evaluate staff performance</span></label> </div> <div class="checkboxGroup"> <input id="svapdxE2_1:dosStfTime" type="checkbox" name="svapdxE2_1:dosStfTime" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxE2_1:lbldosStfTime" for="svapdxE2_1:dosStfTime" class="outputLabel"> <span id="svapdxE2_1:lbltxtdosStfTime" class="outputText">Verify time worked by staff and approve time sheets</span></label> </div> <div class="checkboxGroup"> <input id="svapdxE2_1:dosStfDisc" type="checkbox" name="svapdxE2_1:dosStfDisc" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxE2_1:lbldosStfDisc" for="svapdxE2_1:dosStfDisc" class="outputLabel"> <span id="svapdxE2_1:lbltxtdosStfDisc" class="outputText">Discharge staff (common law employer)</span></label> </div> <div class="checkboxGroup"> <input id="svapdxE2_1:dosStfDiscSvc" type="checkbox" name="svapdxE2_1:dosStfDiscSvc" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxE2_1:lbldosStfDiscSvc" for="svapdxE2_1:dosStfDiscSvc" class="outputLabel"> <span id="svapdxE2_1:lbltxtdosStfDiscSvc" class="outputText">Discharge staff from providing services (co-employer)</span></label> </div> <div class="checkboxGroup"> <input id="svapdxE2_1:dosStfOth" type="checkbox" name="svapdxE2_1:dosStfOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxE2_1:lbldosStfOth" for="svapdxE2_1:dosStfOth" class="outputLabel"> <span id="svapdxE2_1:lbltxtdosStfOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <!-- rendered="#{(varFactory.dosStfOth) ? true : false}"> --> <p class="outputTextNB"> <label id="svapdxE2_1:lbldosStfOthDscr" for="svapdxE2_1:dosStfOthDscr" class="outputLabel"> <span id="svapdxE2_1:lbltxtdosStfOthDscr" class="outputTextNB">Specify:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxE2_1:dosStfOthDscrChrCntLbl" for="svapdxE2_1:dosStfOthDscrChrCnt" class="outputLabel"> <span id="svapdxE2_1:dosStfOthDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxE2_1:dosStfOthDscrChrCnt" type="text" name="svapdxE2_1:dosStfOthDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxE2_1:dosStfOthDscrChrCntMax" class="chrCnt"> out of 4000</span> </div> <div class="inputTextareaWA"> <span id="svapdxE2_1:panel_dosStfOthDscr"><textarea id="svapdxE2_1:dosStfOthDscr" name="svapdxE2_1:dosStfOthDscr" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> </LI> </OL> </LI> </OL> <H2 id="pageTitle">Appendix E: Participant Direction of Services</H2> <H3 id="pageSubTitle">E-2: Opportunities for Participant-Direction <SPAN id="pageNumber">(2 of 6)</SPAN></H3> <OL class="alphaLC" start="2"> <LI><P class="outputTextNB"><STRONG>Participant - Budget Authority</STRONG><em> Complete when the waiver offers the budget authority opportunity as indicated in Item E-1-b:</em></P> <DIV> <p class="pph underline bld outputText"> <span id="svapdxE2_2:donotcompleteE12" class="outputText">Answers provided in Appendix E-1-b indicate that you do not need to complete this section.</span> </p> </DIV> <OL class="romanLC" start="1"> <LI><P class="outputTextNB"><STRONG>Participant Decision Making Authority.</STRONG> When the participant has budget authority, indicate the decision-making authority that the participant may exercise over the budget. <EM>Select one or more</EM>:</P> <DIV class="checkboxGroup"> <input id="svapdxE2_2:dosBudReall" type="checkbox" name="svapdxE2_2:dosBudReall" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxE2_2:lbldosBudReall" for="svapdxE2_2:dosBudReall" class="outputLabel"> <span id="svapdxE2_2:lbltxtdosBudReall" class="outputText">Reallocate funds among services included in the budget</span></label> </DIV> <DIV class="checkboxGroup"> <input id="svapdxE2_2:dosBudDetFees" type="checkbox" name="svapdxE2_2:dosBudDetFees" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxE2_2:lbldosBudDetFees" for="svapdxE2_2:dosBudDetFees" class="outputLabel"> <span id="svapdxE2_2:text2" class="outputText">Determine the amount paid for services within the State's established limits</span></label> </DIV> <DIV class="checkboxGroup"> <input id="svapdxE2_2:dosBudSubPrvd" type="checkbox" name="svapdxE2_2:dosBudSubPrvd" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxE2_2:lbldosBudSubPrvd" for="svapdxE2_2:dosBudSubPrvd" class="outputLabel"> <span id="svapdxE2_2:lbltxtdosBudSubPrvd" class="outputText">Substitute service providers</span></label> </DIV> <DIV class="checkboxGroup"> <input id="svapdxE2_2:dosBudSchSvc" type="checkbox" name="svapdxE2_2:dosBudSchSvc" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxE2_2:lbldosBudSchSvc" for="svapdxE2_2:dosBudSchSvc" class="outputLabel"> <span id="svapdxE2_2:lbltxtdosBudSchSvc" class="outputText">Schedule the provision of services</span></label> </DIV> <DIV class="checkboxGroup"> <input id="svapdxE2_2:dosBudAddSvc" type="checkbox" name="svapdxE2_2:dosBudAddSvc" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxE2_2:lbldosBudAddSvc" for="svapdxE2_2:dosBudAddSvc" class="outputLabel"> <span id="svapdxE2_2:lbltxtdosBudAddSvc" class="outputText">Specify additional service provider qualifications consistent with the qualifications specified in Appendix C-1/C-3</span></label> </DIV> <DIV class="checkboxGroup"> <input id="svapdxE2_2:dosBudSvcProMth" type="checkbox" name="svapdxE2_2:dosBudSvcProMth" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxE2_2:lbldosBudSvcProMth" for="svapdxE2_2:dosBudSvcProMth" class="outputLabel"> <span id="svapdxE2_2:lbltxtdosBudSvcProMth" class="outputText">Specify how services are provided, consistent with the service specifications contained in Appendix C-1/C-3</span></label> </DIV> <DIV class="checkboxGroup"> <input id="svapdxE2_2:dosBudIdPrvdr" type="checkbox" name="svapdxE2_2:dosBudIdPrvdr" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxE2_2:lbldosBudIdPrvdr" for="svapdxE2_2:dosBudIdPrvdr" class="outputLabel"> <span id="svapdxE2_2:lbltxtdosBudIdPrvdr" class="outputText">Identify service providers and refer for provider enrollment</span></label> </DIV> <DIV class="checkboxGroup"> <input id="svapdxE2_2:dosBudAuthPay" type="checkbox" name="svapdxE2_2:dosBudAuthPay" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxE2_2:lbldosBudAuthPay" for="svapdxE2_2:dosBudAuthPay" class="outputLabel"> <span id="svapdxE2_2:lbltxtdosBudAuthPay" class="outputText">Authorize payment for waiver goods and services</span></label> </DIV> <DIV class="checkboxGroup"> <input id="svapdxE2_2:dosBudRevInv" type="checkbox" name="svapdxE2_2:dosBudRevInv" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxE2_2:lbldosBudRevInv" for="svapdxE2_2:dosBudRevInv" class="outputLabel"> <span id="svapdxE2_2:lbltxtdosBudRevInv" class="outputText">Review and approve provider invoices for services rendered</span></label> </DIV> <DIV class="checkboxGroup"> <input id="svapdxE2_2:dosBudOth" type="checkbox" name="svapdxE2_2:dosBudOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxE2_2:lbldosBudOth" for="svapdxE2_2:dosBudOth" class="outputLabel"> <span id="svapdxE2_2:lbltxtdosBudOth" class="outputText">Other</span></label> </DIV> <div class="firstIndent"> <!-- rendered="#{(varFactory.dosBudOth ) ? true : false}"> --> <p class="outputTextNB"> <label id="svapdxE2_2:lbldosBudOthDscr" for="svapdxE2_2:dosBudOthDscr" class="outputLabel"> <span id="svapdxE2_2:lbltxtdosBudOthDscr" class="outputTextNB">Specify:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxE2_2:dosBudOthDscrChrCntLbl" for="svapdxE2_2:dosBudOthDscrChrCnt" class="outputLabel"> <span id="svapdxE2_2:dosBudOthDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxE2_2:dosBudOthDscrChrCnt" type="text" name="svapdxE2_2:dosBudOthDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxE2_2:dosBudOthDscrChrCntMax" class="chrCnt"> out of 4000</span> </div> <div class="inputTextareaWA"> <span id="svapdxE2_2:panel_dosBudOthDscr"><textarea id="svapdxE2_2:dosBudOthDscr" name="svapdxE2_2:dosBudOthDscr" class="inputTextareaLong" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> </LI> </OL> </LI> </OL> <H2 id="pageTitle">Appendix E: Participant Direction of Services</H2> <H3 id="pageSubTitle">E-2: Opportunities for Participant-Direction <SPAN id="pageNumber">(3 of 6)</SPAN></H3> <OL class="alphaLC" start="2"> <LI><P class="outputTextNB"><STRONG>Participant - Budget Authority</STRONG></P> <DIV> <p class="pph underline bld outputText"> <span id="svapdxE2_3:donotcompleteE12" class="outputText">Answers provided in Appendix E-1-b indicate that you do not need to complete this section.</span> </p> </DIV> <OL class="romanLC" start="2"> <LI><P class="outputTextNB"> <STRONG>Participant-Directed Budget</STRONG> <label id="svapdxE2_3:lbldosBudEstMth" for="svapdxE2_3:dosBudEstMth" class="outputLabel"> <span id="svapdxE2_3:lbltxtdosBudEstMth" class="outputTextNB">Describe in detail the method(s) that are used to establish the amount of the participant-directed budget for waiver goods and services over which the participant has authority, including how the method makes use of reliable cost estimating information and is applied consistently to each participant. Information about these method(s) must be made publicly available.</span></label> </P> <p></p> <div class="chrCntDiv"> <label id="svapdxE2_3:dosBudEstMthChrCntLbl" for="svapdxE2_3:dosBudEstMthChrCnt" class="outputLabel"> <span id="svapdxE2_3:dosBudEstMthChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxE2_3:dosBudEstMthChrCnt" type="text" name="svapdxE2_3:dosBudEstMthChrCnt" class="chrCnt" size="6" /><span id="svapdxE2_3:dosBudEstMthChrCntMax" class="chrCnt"> out of 12000</span> </div> <DIV class="inputTextareaWA"> <span id="svapdxE2_3:panel_dosBudEstMth"><textarea id="svapdxE2_3:dosBudEstMth" name="svapdxE2_3:dosBudEstMth" class="inputTextareaLong" onkeyup="Count(this);" readonly="readonly"></textarea></span> </DIV> </LI> </OL> </LI> </OL> <H2 id="pageTitle">Appendix E: Participant Direction of Services</H2> <H3 id="pageSubTitle">E-2: Opportunities for Participant-Direction <SPAN id="pageNumber">(4 of 6)</SPAN></H3> <OL class="alphaLC" start="2"> <LI><P class="outputTextNB"><STRONG>Participant - Budget Authority</STRONG></P> <DIV> <p class="pph underline bld outputText"> <span id="svapdxE2_4:donotcompleteE12" class="outputText">Answers provided in Appendix E-1-b indicate that you do not need to complete this section.</span> </p> </DIV> <OL class="romanLC" start="3"> <LI><P class="outputTextNB"> <STRONG>Informing Participant of Budget Amount. </STRONG> <label id="svapdxE2_4:lbldosBudInfoProc" for="svapdxE2_4:dosBudInfoProc" class="outputLabel"> <span id="svapdxE2_4:lbltxtdosBudInfoProc" class="outputTextNB">Describe how the State informs each participant of the amount of the participant-directed budget and the procedures by which the participant may request an adjustment in the budget amount.</span></label> </P> <p></p> <div class="chrCntDiv"> <label id="svapdxE2_4:dosBudInfoProcChrCntLbl" for="svapdxE2_4:dosBudInfoProcChrCnt" class="outputLabel"> <span id="svapdxE2_4:dosBudInfoProcChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxE2_4:dosBudInfoProcChrCnt" type="text" name="svapdxE2_4:dosBudInfoProcChrCnt" class="chrCnt" size="6" /><span id="svapdxE2_4:dosBudInfoProcChrCntMax" class="chrCnt"> out of 12000</span> </div> <DIV class="inputTextareaWA"> <span id="svapdxE2_4:page_dosBudInfoProc"><textarea id="svapdxE2_4:dosBudInfoProc" name="svapdxE2_4:dosBudInfoProc" class="inputTextareaLong" onkeyup="Count(this);" readonly="readonly"></textarea></span> </DIV> </LI> </OL> </LI> </OL> <H2 id="pageTitle">Appendix E: Participant Direction of Services</H2> <H3 id="pageSubTitle">E-2: Opportunities for Participant-Direction <SPAN id="pageNumber">(5 of 6)</SPAN></H3> <OL class="alphaLC" start="2"> <LI><P class="outputTextNB"><STRONG>Participant - Budget Authority</STRONG></P> <DIV> <p class="pph underline bld outputText"> <span id="svapdxE2_5:donotcompleteE12" class="outputText">Answers provided in Appendix E-1-b indicate that you do not need to complete this section.</span> </p> </DIV> <OL class="romanLC" start="4"> <LI><P class="outputTextNB"> <STRONG>Participant Exercise of Budget Flexibility.</STRONG> <EM>Select one</EM>: </P> <table id="svapdxE2_5:dosBudFlex" class="selectOneRadio"> <tr> <td> <input type="radio" name="svapdxE2_5:dosBudFlex" id="svapdxE2_5:dosBudFlex:0" value="0" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxE2_5:dosBudFlex:0"> Modifications to the participant directed budget must be preceded by a change in the service plan.</label></td> </tr> <tr> <td> <input type="radio" name="svapdxE2_5:dosBudFlex" id="svapdxE2_5:dosBudFlex:1" value="1" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxE2_5:dosBudFlex:1"> The participant has the authority to modify the services included in the participant directed budget without prior approval.</label></td> </tr> </table> <div class="firstIndent"> <!-- rendered="#{(varFactory.dosBudFlex == 1) ? true : false}"> --> <p> <label id="svapdxE2_5:lbldosBudFlexProc" for="svapdxE2_5:dosBudFlexProc" class="outputLabel"> <span id="svapdxE2_5:lbltxtdosBudFlexProc" class="outputTextNB">Specify how changes in the participant-directed budget are documented, including updating the service plan. When prior review of changes is required in certain circumstances, describe the circumstances and specify the entity that reviews the proposed change:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxE2_5:dosBudFlexProcChrCntLbl" for="svapdxE2_5:dosBudFlexProcChrCnt" class="outputLabel"> <span id="svapdxE2_5:dosBudFlexProcChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxE2_5:dosBudFlexProcChrCnt" type="text" name="svapdxE2_5:dosBudFlexProcChrCnt" class="chrCnt" size="6" /><span id="svapdxE2_5:dosBudFlexProcChrCntMax" class="chrCnt"> out of 12000</span> </div> <DIV class="inputTextareaWA"> <span id="svapdxE2_5:panel_dosBudFlexProc"><textarea id="svapdxE2_5:dosBudFlexProc" name="svapdxE2_5:dosBudFlexProc" class="inputTextareaLong" onkeyup="Count(this);" readonly="readonly"></textarea></span> </DIV> </div> </LI> </OL> </LI> </OL> <H2 id="pageTitle">Appendix E: Participant Direction of Services</H2> <H3 id="pageSubTitle">E-2: Opportunities for Participant-Direction <SPAN id="pageNumber">(6 of 6)</SPAN></H3> <OL class="alphaLC" start="2"> <LI><P class="outputTextNB"><STRONG>Participant - Budget Authority</STRONG></P> <DIV> <p class="pph underline bld outputText"> <span id="svapdxE2_6:donotcompleteE12" class="outputText">Answers provided in Appendix E-1-b indicate that you do not need to complete this section.</span> </p> </DIV> <OL class="romanLC" start="5"> <LI><P class="outputTextNB"> <STRONG>Expenditure Safeguards.</STRONG> <label id="svapdxE2_6:lbldosBudSfg" for="svapdxE2_6:dosBudSfg" class="outputLabel"> <span id="svapdxE2_6:lbltxtdosBudSfg" class="outputTextNB">Describe the safeguards that have been established for the timely prevention of the premature depletion of the participant-directed budget or to address potential service delivery problems that may be associated with budget underutilization and the entity (or entities) responsible for implementing these safeguards:</span></label> </P> <p></p> <div class="chrCntDiv"> <label id="svapdxE2_6:dosBudSfgChrCntLbl" for="svapdxE2_6:dosBudSfgChrCnt" class="outputLabel"> <span id="svapdxE2_6:dosBudSfgChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxE2_6:dosBudSfgChrCnt" type="text" name="svapdxE2_6:dosBudSfgChrCnt" class="chrCnt" size="6" /><span id="svapdxE2_6:dosBudSfgChrCntMax" class="chrCnt"> out of 12000</span> </div> <DIV class="inputTextareaWA"> <span id="svapdxE2_6:panel_dosBudSfg"><textarea id="svapdxE2_6:dosBudSfg" name="svapdxE2_6:dosBudSfg" class="inputTextareaLong" onkeyup="Count(this);" readonly="readonly"></textarea></span> </DIV> </LI> </OL> </LI> </OL> <H2 id="pageTitle">Appendix F: Participant Rights</H2> <H3 id="pageSubTitle">Appendix F-1: Opportunity to Request a Fair Hearing</H3> <div> <p class="outputTextNB"> The State provides an opportunity to request a Fair Hearing under 42 CFR Part 431, Subpart E to individuals: (a) who are not given the choice of home and community-based services as an alternative to the institutional care specified in Item 1-F of the request; (b) are denied the service(s) of their choice or the provider(s) of their choice; or, (c) whose services are denied, suspended, reduced or terminated. The State provides notice of action as required in 42 CFR §431.210. </p> </div> <div> <p class="outputTextNB"> <STRONG>Procedures for Offering Opportunity to Request a Fair Hearing.</STRONG> <label id="svapdxF1_1:lblrtsFrHrngInfoMth" for="svapdxF1_1:rtsFrHrngInfoMth" class="outputLabel"> <span id="svapdxF1_1:lbltxtrtsFrHrngInfoMth" class="outputTextNB"> Describe how the individual (or his/her legal representative) is informed of the opportunity to request a fair hearing under 42 CFR Part 431, Subpart E. Specify the notice(s) that are used to offer individuals the opportunity to request a Fair Hearing. State laws, regulations, policies and notices referenced in the description are available to CMS upon request through the operating or Medicaid agency.</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxF1_1:rtsFrHrngInfoMthChrCntLbl" for="svapdxF1_1:rtsFrHrngInfoMthChrCnt" class="outputLabel"> <span id="svapdxF1_1:rtsFrHrngInfoMthChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxF1_1:rtsFrHrngInfoMthChrCnt" type="text" name="svapdxF1_1:rtsFrHrngInfoMthChrCnt" class="chrCnt" size="6" /><span id="svapdxF1_1:rtsFrHrngInfoMthChrCntMax" class="chrCnt"> out of 12000</span> </div> <DIV class="inputTextareaWA"> <span id="svapdxF1_1:panel_rtsFrHrngInfoMth"><textarea id="svapdxF1_1:rtsFrHrngInfoMth" name="svapdxF1_1:rtsFrHrngInfoMth" class="inputTextareaLong" onkeyup="Count(this);" readonly="readonly">Applicants for and recipients of services under the PCA Waiver, may request and receive a fair hearing, in accordance with the rules of the Department's Medical Assistance Program. The W-944 notice of action form is issued by a care manager when services are reduced, denied or suspended. For active participants who are notified of a reduction or elimination of a particular service, it states that services will not be discontinued during the fair hearing process, if the request for fair hearing is received by the department prior to the effective date of the service change in the notice. Care managers will notify clients of this and do not stop services until after a fair hearing decision is issued. Fair Hearings are provided in the following circumstances: When the Department: 1. did not offer the choice of home and community-based services as an alternative to institutional care 2. does not reach a determination of financial eligibility within the department'’s standard of promptness 3. denies the application for any reasons other than the limitations on the number of individuals who can be served and/or funding limitations as established in the approved PCA waiver 4. disapproves the individual's service plan 5. denies or terminates a service of the individual's choice 6. denies or terminates payment to a qualified provider of the individual&Acirc;’s choice or; 7. discharges the individual from the PCA waiver program In accordance with Medicaid rules (Connecticut General Statutes (17b-60-66), a Notice of Action (NOA) is issued to waiver participants when any service is denied, reduced, suspended or terminated. The NOA and Freedom of Choice/Fair Hearing notification are also provided in Spanish to support providing persons with LEP or Non-English proficiency. The Office of Legal Council, fair hearings unit, keep a record of all fair hearings and the results of any cases heard.</textarea></span> </DIV> </div> <H2 id="pageTitle">Appendix F: Participant-Rights</H2> <H3 id="pageSubTitle">Appendix F-2: Additional Dispute Resolution Process</H3> <OL class="alphaLC" start="1"> <LI> <P class="outputTextNB"> <STRONG>Availability of Additional Dispute Resolution Process.</STRONG> Indicate whether the State operates another dispute resolution process that offers participants the opportunity to appeal decisions that adversely affect their services while preserving their right to a Fair Hearing. <EM>Select one:</EM> </P> <DIV class="checkboxGroup"><label><input id="svapdxF2_1:rtsDispResAddAvl:0" type="radio" name="svapdxF2_1:rtsDispResAddAvl" checked="checked" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;No. This Appendix does not apply</label></DIV> <DIV class="checkboxGroup"><label><input id="svapdxF2_1:rtsDispResAddAvl:1" type="radio" name="svapdxF2_1:rtsDispResAddAvl" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;Yes. The State operates an additional dispute resolution process</label></DIV> <DIV class="noShow"><label><input id="svapdxF2_1:rtsDispResAddAvl:2" type="radio" name="svapdxF2_1:rtsDispResAddAvl" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></DIV> </LI> <!-- rendered="#{(varFactory.rtsDispResAddAvl == 1)?true:false}"> --> <LI> <p class="outputTextNB"> <STRONG>Description of Additional Dispute Resolution Process.</STRONG> <label id="svapdxF2_1:lblrtsDispResAddDscr" for="svapdxF2_1:rtsDispResAddDscr" class="outputLabel"> <span id="svapdxF2_1:lbltxtrtsDispResAddDscr" class="outputTextNB"> Describe the additional dispute resolution process, including: (a) the State agency that operates the process; (b) the nature of the process (i.e., procedures and timeframes), including the types of disputes addressed through the process; and, (c) how the right to a Medicaid Fair Hearing is preserved when a participant elects to make use of the process: State laws, regulations, and policies referenced in the description are available to CMS upon request through the operating or Medicaid agency.</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxF2_1:rtsDispResAddDscrChrCntLbl" for="svapdxF2_1:rtsDispResAddDscrChrCnt" class="outputLabel"> <span id="svapdxF2_1:rtsDispResAddDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxF2_1:rtsDispResAddDscrChrCnt" type="text" name="svapdxF2_1:rtsDispResAddDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxF2_1:rtsDispResAddDscrChrCntMax" class="chrCnt"> out of 12000</span> </div> <DIV class="inputTextareaWA"> <span id="svapdxF2_1:panel_rtsDispResAddDscr"><textarea id="svapdxF2_1:rtsDispResAddDscr" name="svapdxF2_1:rtsDispResAddDscr" class="inputTextareaLong" onkeyup="Count(this);" readonly="readonly"></textarea></span> </DIV> </LI> </OL> <H2 id="pageTitle">Appendix F: Participant-Rights</H2> <H3 id="pageSubTitle">Appendix F-3: State Grievance/Complaint System</H3> <OL class="alphaLC" start="1"> <LI> <P class="outputTextNB"> <STRONG>Operation of Grievance/Complaint System.</STRONG> <em>Select one:</em> </P> <DIV class="checkboxGroup"><label><input id="svapdxF3_1:rtsGrvSys:0" type="radio" name="svapdxF3_1:rtsGrvSys" checked="checked" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;No. This Appendix does not apply</label></DIV> <DIV class="checkboxGroup"><label><input id="svapdxF3_1:rtsGrvSys:1" type="radio" name="svapdxF3_1:rtsGrvSys" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;Yes. The State operates a grievance/complaint system that affords participants the opportunity to register grievances or complaints concerning the provision of services under this waiver</label></DIV> <DIV class="noShow"><label><input id="svapdxF3_1:rtsGrvSys:2" type="radio" name="svapdxF3_1:rtsGrvSys" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></DIV> </LI> <!-- rendered="#{(varFactory.rtsGrvSys == 1)?true:false}"> --> <LI> <P> <STRONG>Operational Responsibility.</STRONG> <label id="svapdxF3_1:lblrtsGrvSysOpAg" for="svapdxF3_1:rtsGrvSysOpAg" class="outputLabel"> <span id="svapdxF3_1:lbltxtrtsGrvSysOpAg" class="outputTextNB"> Specify the State agency that is responsible for the operation of the grievance/complaint system:</span></label> </P> <p></p> <div class="chrCntDiv"> <label id="svapdxF3_1:rtsGrvSysOpAgChrCntLbl" for="svapdxF3_1:rtsGrvSysOpAgChrCnt" class="outputLabel"> <span id="svapdxF3_1:rtsGrvSysOpAgChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxF3_1:rtsGrvSysOpAgChrCnt" type="text" name="svapdxF3_1:rtsGrvSysOpAgChrCnt" class="chrCnt" size="6" /><span id="svapdxF3_1:rtsGrvSysOpAgChrCntMax" class="chrCnt"> out of 4000</span> </div> <DIV class="inputTextareaWA"> <span id="svapdxF3_1:panel_rtsGrvSysOpAg"><textarea id="svapdxF3_1:rtsGrvSysOpAg" name="svapdxF3_1:rtsGrvSysOpAg" class="inputTextarea15" onkeyup="Count(this);" readonly="readonly"></textarea></span> </DIV> </LI> <li> <p> <STRONG>Description of System.</STRONG> <label id="svapdxF3_1:lblrtsGrvSysDscr" for="svapdxF3_1:rtsGrvSysDscr" class="outputLabel"> <span id="svapdxF3_1:lbltxtrtsGrvSysDscr" class="outputTextNB"> Describe the grievance/complaint system, including: (a) the types of grievances/complaints that participants may register; (b) the process and timelines for addressing grievances/complaints; and, (c) the mechanisms that are used to resolve grievances/complaints. State laws, regulations, and policies referenced in the description are available to CMS upon request through the Medicaid agency or the operating agency (if applicable).</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxF3_1:rtsGrvSysDscrChrCntLbl" for="svapdxF3_1:rtsGrvSysDscrChrCnt" class="outputLabel"> <span id="svapdxF3_1:rtsGrvSysDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxF3_1:rtsGrvSysDscrChrCnt" type="text" name="svapdxF3_1:rtsGrvSysDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxF3_1:rtsGrvSysDscrChrCntMax" class="chrCnt"> out of 12000</span> </div> <DIV class="inputTextareaWA"> <span id="svapdxF3_1:panel_rtsGrvSysDscr"><textarea id="svapdxF3_1:rtsGrvSysDscr" name="svapdxF3_1:rtsGrvSysDscr" class="inputTextarea25" onkeyup="Count(this);" readonly="readonly"></textarea></span> </DIV> </li> </OL> <H2 id="pageTitle">Appendix G: Participant Safeguards</H2> <H3 id="pageSubTitle">Appendix G-1: Response to Critical Events or Incidents</H3> <OL class="alphaLC" start="1"> <LI> <P class="outputTextNB"> <STRONG>Critical Event or Incident Reporting and Management Process.</STRONG> <label id="svapdxG1_1:lblsfgCrEvRpt" for="svapdxG1_1:sfgCrEvRpt" class="outputLabel"> <span id="svapdxG1_1:lbltxtsfgCrEvRpt1" class="outputTextNB">Indicate whether the State operates Critical Event or Incident Reporting and Management Process that enables the State to collect information on sentinel events occurring in the waiver program.</span><span id="svapdxG1_1:lbltxtsfgCrEvRpt2" class="outputTextNB em">Select one: </span></label> </P> <div class="noShow"><label><input id="svapdxG1_1:sfgCrEvRpt:2" type="radio" name="svapdxG1_1:sfgCrEvRpt" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> <div class="checkboxGroup"> <label><input id="svapdxG1_1:sfgCrEvRpt:0" type="radio" name="svapdxG1_1:sfgCrEvRpt" checked="checked" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;Yes. The State operates a Critical Event or Incident Reporting and Management Process</label> <span class="outputTextNB em"> (complete Items b through e)</span> </div> <div class="checkboxGroup"> <label><input id="svapdxG1_1:sfgCrEvRpt:1" type="radio" name="svapdxG1_1:sfgCrEvRpt" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;No. This Appendix does not apply</label> <span class="outputTextNB em"> (do not complete Items b through e)</span> </div> <div class="firstIndent"> <label id="svapdxG1_1:lblsfgCrEvRptNa" for="svapdxG1_1:sfgCrEvRptNa" class="outputLabel"> <span id="svapdxG1_1:lbltxtsfgCrEvRptNa" class="outputTextNB">If the State does not operate a Critical Event or Incident Reporting and Management Process, describe the process that the State uses to elicit information on the health and welfare of individuals served through the program.</span></label> <p></p> <div class="chrCntDiv"> <label id="svapdxG1_1:sfgCrEvRptNaChrCntLbl" for="svapdxG1_1:sfgCrEvRptNaChrCnt" class="outputLabel"> <span id="svapdxG1_1:sfgCrEvRptNaChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxG1_1:sfgCrEvRptNaChrCnt" type="text" name="svapdxG1_1:sfgCrEvRptNaChrCnt" class="chrCnt" size="6" /><span id="svapdxG1_1:sfgCrEvRptNaChrCntMax" class="chrCnt"> out of 12000</span> </div> <DIV class="inputTextareaWA"> <span id="svapdxG1_1:panel_sfgCrEvRptNa"><textarea id="svapdxG1_1:sfgCrEvRptNa" name="svapdxG1_1:sfgCrEvRptNa" class="inputTextarea25" onkeyup="Count(this);" readonly="readonly"></textarea></span> </DIV> </div> </LI> <LI> <P class="outputTextNB"> <STRONG>State Critical Event or Incident Reporting Requirements. </STRONG> <label id="svapdxG1_1:lblsfgCrEvRptRqmts" for="svapdxG1_1:sfgCrEvRptRqmts" class="outputLabel"> <span id="svapdxG1_1:lbltxtsfgCrEvRptRqmts" class="outputTextNB"> Specify the types of critical events or incidents (including alleged abuse, neglect and exploitation) that the State requires to be reported for review and follow-up action by an appropriate authority, the individuals and/or entities that are required to report such events and incidents and the timelines for reporting. State laws, regulations, and policies that are referenced are available to CMS upon request through the Medicaid agency or the operating agency (if applicable).</span></label> </P> <p></p> <div class="chrCntDiv"> <label id="svapdxG1_1:sfgCrEvRptRqmtsChrCntLbl" for="svapdxG1_1:sfgCrEvRptRqmtsChrCnt" class="outputLabel"> <span id="svapdxG1_1:sfgCrEvRptRqmtsChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxG1_1:sfgCrEvRptRqmtsChrCnt" type="text" name="svapdxG1_1:sfgCrEvRptRqmtsChrCnt" class="chrCnt" size="6" /><span id="svapdxG1_1:sfgCrEvRptRqmtsChrCntMax" class="chrCnt"> out of 24000</span> </div> <DIV class="inputTextareaWA"> <span id="svapdxG1_1:panel_sfgCrEvRptRqmts"><textarea id="svapdxG1_1:sfgCrEvRptRqmts" name="svapdxG1_1:sfgCrEvRptRqmts" class="inputTextarea25" onkeyup="Count(this);" readonly="readonly">The Department seeks to identify, address and prevent instances of abuse, neglect and exploitation. For consistency in programming, the Waiver managers team in collaboration with the Director of Money Follows the Person have developed a critical incident reporting form. A reportable incident is defined as any situation in which the waiver participant experiences a perceived or actual threat to his/her welfare or to their ability to remain in the community. These incidents include: - Allegations of physical, sexual and psychological abuse, seclusion, violation of civil rights, mistreatment, neglect and exploitation - Missing persons-• - Death of a waiver participant -• Criminal action• - Prolonged unplanned hospitalization Reporting Methods and time frames: All critical incidents are reported immediately to the HCBS Unit clinical staff. Beginning October 1, 2009 the fiscal intermediary utilized the State approved Critical Incident Reporting form to notify DSS Managers or delegated clinical staff of any incidents reported to them. The current process is that the fiscal intermediary will send a report that they generate to the Program Manager to assign and investigate on a case by case basis and take the appropriate action. Protective Services in CT applies only to persons age 60 and over and there are specific mandatory reporting requirements and timeframes depending on the severity of the incident. For our critical incident reporting system, our goal is to review and take action on any critical incident report in 48-72 hours. Emergent situations such as missing persons are addressed upon receipt The time to complete the investigation varies depending on the type, nature and severity of the incident. Police are notified immediately in the event of potential criminal activity or a missing person. The individual or their representative is notified of the outcome of the investigation upon completion. Ct does not have Adult Protective Services only Protective Services for Elders and statutorily only persons age 60 or over can be served.</textarea></span> </DIV> </LI> <LI> <P class="outputTextNB"> <STRONG>Participant Training and Education. </STRONG> <label id="svapdxG1_1:lblsfgCrEvPtcTrn" for="svapdxG1_1:sfgCrEvPtcTrn" class="outputLabel"> <span id="svapdxG1_1:lbltxtsfgCrEvPtcTrn" class="outputTextNB"> Describe how training and/or information is provided to participants (and/or families or legal representatives, as appropriate) concerning protections from abuse, neglect, and exploitation, including how participants (and/or families or legal representatives, as appropriate) can notify appropriate authorities or entities when the participant may have experienced abuse, neglect or exploitation.</span></label> </P> <p></p> <div class="chrCntDiv"> <label id="svapdxG1_1:sfgCrEvPtcTrnChrCntLbl" for="svapdxG1_1:sfgCrEvPtcTrnChrCnt" class="outputLabel"> <span id="svapdxG1_1:sfgCrEvPtcTrnChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxG1_1:sfgCrEvPtcTrnChrCnt" type="text" name="svapdxG1_1:sfgCrEvPtcTrnChrCnt" class="chrCnt" size="6" /><span id="svapdxG1_1:sfgCrEvPtcTrnChrCntMax" class="chrCnt"> out of 12000</span> </div> <DIV class="inputTextareaWA"> <span id="svapdxG1_1:panel_sfgCrEvPtcTrn"><textarea id="svapdxG1_1:sfgCrEvPtcTrn" name="svapdxG1_1:sfgCrEvPtcTrn" class="inputTextarea25" onkeyup="Count(this);" readonly="readonly">QI strategy: DSS has developed a brochure that clearly articulates the appropriate parties to contact regarding potential abuse, neglect or exploitation of waiver participants. This brochure will be given to the fiscal intermediary to provide education and training to consumers/representatives during the orientation to the program. Consumers/representatives will be informed of the necessity to report events to their social worker or to the fiscal intermediary immediately. All participants will sign the Right and Responsibilities form to evidence that such information has been given. As a best practice we will begin to incorporate a discussion of reporting abuse/neglect into the annual reassessment process.</textarea></span> </DIV> </LI> <LI> <P class="outputTextNB"> <STRONG>Responsibility for Review of and Response to Critical Events or Incidents. </STRONG> <label id="svapdxG1_1:lblsfgCrEvRspRev" for="svapdxG1_1:sfgCrEvRspRev" class="outputLabel"> <span id="svapdxG1_1:lbltxtsfgCrEvRspRev" class="outputTextNB"> Specify the entity (or entities) that receives reports of critical events or incidents specified in item G-1-a, the methods that are employed to evaluate such reports, and the processes and time-frames for responding to critical events or incidents, including conducting investigations.</span></label> </P> <p></p> <div class="chrCntDiv"> <label id="svapdxG1_1:sfgCrEvRspRevChrCntLbl" for="svapdxG1_1:sfgCrEvRspRevChrCnt" class="outputLabel"> <span id="svapdxG1_1:sfgCrEvRspRevChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxG1_1:sfgCrEvRspRevChrCnt" type="text" name="svapdxG1_1:sfgCrEvRspRevChrCnt" class="chrCnt" size="6" /><span id="svapdxG1_1:sfgCrEvRspRevChrCntMax" class="chrCnt"> out of 12000</span> </div> <DIV class="inputTextareaWA"> <span id="svapdxG1_1:panel_sfgCrEvRspRev"><textarea id="svapdxG1_1:sfgCrEvRspRev" name="svapdxG1_1:sfgCrEvRspRev" class="inputTextarea25" onkeyup="Count(this);" readonly="readonly">The DSS investigates any serious issues or refers the issue to the appropriate agency. DSS will interview the consumer, and any other parties that were involved, or have knowledge of the incident. The specific manner for follow-up is determined by the nature of the allegation and the results of the investigation. Possible actions include the suspension or removal of the consumer from the program, or the PCA from the registry. Reporting to law enforcement is also possible. Action to ensure the safety of a waiver participant who is at imminent risk occurs immediately. Additional follow-up may include referrals to other DSS divisions, such as Quality Assurance, Medical Policy or the Legal department. When a waiver participant is age sixty or older and it is deemed appropriate to contact Protective Services for the Elderly (PSE) as part of the investigation the social worker, as a mandated reporter, will assure this is done. In addition, police are notified if any criminal action occurs. Any party involved in the investigation process may initiate contact with PSE or the police. All contacts with PSE and/or the police must be documented as part of the investigation process. PSE Statute 17b-450-461 provides the framework for the investigation of abuse or neglect. The Waiver Managers team coordinated with the Money Follows the Person Director to develop a system that facilitates: -Analysis of the types and numbers of complaints at a systemic level- -Looking for trends by area -Identifying statewide issues -Developing and implementing plans for improvement The electronic system was delayed and not implemented consequently, the current system is paper based. With the transition of the management of the PCA waiver to the Alternate Care unit, this waiver will be able to utilize the system in an existing web based system. This system has been operational since May of 2013 and has had several modifications and upgrades for enhanced functioning. This system is working extremely well and allows for the identification of trends. It has the ability to track individual remediation as well.</textarea></span> </DIV> </LI> <LI> <P class="outputTextNB"> <STRONG>Responsibility for Oversight of Critical Incidents and Events. </STRONG> <label id="svapdxG1_1:lblsfgCrEvRptOvrst" for="svapdxG1_1:sfgCrEvRptOvrst" class="outputLabel"> <span id="svapdxG1_1:lbltxtsfgCrEvRptOvrst" class="outputTextNB"> Identify the State agency (or agencies) responsible for overseeing the reporting of and response to critical incidents or events that affect waiver participants, how this oversight is conducted, and how frequently.</span></label> </P> <p></p> <div class="chrCntDiv"> <label id="svapdxG1_1:sfgCrEvRptOvrstChrCntLbl" for="svapdxG1_1:sfgCrEvRptOvrstChrCnt" class="outputLabel"> <span id="svapdxG1_1:sfgCrEvRptOvrstChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxG1_1:sfgCrEvRptOvrstChrCnt" type="text" name="svapdxG1_1:sfgCrEvRptOvrstChrCnt" class="chrCnt" size="6" /><span id="svapdxG1_1:sfgCrEvRptOvrstChrCntMax" class="chrCnt"> out of 12000</span> </div> <DIV class="inputTextareaWA"> <span id="svapdxG1_1:panel_sfgCrEvRptOvrst"><textarea id="svapdxG1_1:sfgCrEvRptOvrst" name="svapdxG1_1:sfgCrEvRptOvrst" class="inputTextarea25" onkeyup="Count(this);" readonly="readonly">DSS is responsible for overseeing the reporting of and response to critical incidents or events that affect waiver participants. The Department directly administers this and follow-up frequency is ongoing. this process is currently being done manually generally in 48-72 hours of receipt unless it is an emergency situations such as a missing person. Incidents are reviewed as they are received and assigned to clinical staff for follow up and investigation. Actions are taken depending on the nature of the incident. For example, if an incident involving a provider neglecting a participant, if this is substantiated by the investigation, the provider would be terminated, removed from the registry and employer retraining might be offered to the participant. The investigation would be a collaboration between the fiscal intermediary and the care manager.</textarea></span> </DIV> </LI> </OL> <H2 id="pageTitle">Appendix G: Participant Safeguards</H2> <H3 id="pageSubTitle">Appendix G-2: Safeguards Concerning Restraints and Restrictive Interventions <SPAN id="pageNumber">(1 of 3)</SPAN></H3> <OL class="alphaLC" start="1"> <LI> <P class="outputTextNB"> <strong>Use of Restraints.</strong> <em>(Select one)</em>: <span class="paragraph em"> (For waiver actions submitted before March 2014, responses in Appendix G-2-a will display information for both restraints and seclusion. For most waiver actions submitted after March 2014, responses regarding seclusion appear in Appendix G-2-c.) </span> </P> <div class="checkboxGroup"><label><input id="svapdxG2_1:sfgRstrntAlwd:0" type="radio" name="svapdxG2_1:sfgRstrntAlwd" checked="checked" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;The State does not permit or prohibits the use of restraints</label></div> <div class="firstIndent"> <p class="outputTextNB"> <label id="svapdxG2_1:lblsfgRstrntAlwdOvrst" for="svapdxG2_1:sfgRstrntAlwdOvrst" class="outputLabel"> <span id="svapdxG2_1:lbltxtsfgRstrntAlwdOvrst" class="outputTextNB">Specify the State agency (or agencies) responsible for detecting the unauthorized use of restraints and how this oversight is conducted and its frequency:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxG2_1:sfgRstrntAlwdOvrstChrCntLbl" for="svapdxG2_1:sfgRstrntAlwdOvrstChrCnt" class="outputLabel"> <span id="svapdxG2_1:sfgRstrntAlwdOvrstChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxG2_1:sfgRstrntAlwdOvrstChrCnt" type="text" name="svapdxG2_1:sfgRstrntAlwdOvrstChrCnt" class="chrCnt" size="6" /><span id="svapdxG2_1:sfgRstrntAlwdOvrstChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxG2_1:panel_sfgRstrntAlwdOvrst"><textarea id="svapdxG2_1:sfgRstrntAlwdOvrst" name="svapdxG2_1:sfgRstrntAlwdOvrst" class="inputTextarea25" onkeyup="Count(this);" readonly="readonly">At any time a client, community provider or any citizen can report to the DSS staff that a client may have been restrained or placed in seclusion. Because the use of restaints are unauthorized and pursuant to Connecticut State PCA Regulation 262-596 (d) the Department reserves the right to terminate any provider who violates any rules or policies of the PCA program. Any use of restraints or seclusion would be a violation of program rules resulting in the provider being terminated and his/her name would be removed from the registry. Employers will also be encouraged and counseled to notify the police if the situation warrants such an intervention. Participants are advised of their rights that prohibits restraints in the employer guide that is given to each new waiver participant. Effective 4/1/15, the state intends to launch a new core standardized assessment that will be used across all waiver programs. The tool with specifically ask questions to determine if there have been any incidents of restraints and will be conducted on an annual basis. The care managers will review this with the clients at each reassessment and also encourage the client to contact them directly if there are any concerns that arise between visits.</textarea></span> </div> </div> <div class="checkboxGroup"><label><input id="svapdxG2_1:sfgRstrntAlwd:1" type="radio" name="svapdxG2_1:sfgRstrntAlwd" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;The use of restraints is permitted during the course of the delivery of waiver services</label><span class="outputTextNB">. Complete Items G-2-a-i and G-2-a-ii.</span></div> <div class="noShow"><label><input id="svapdxG2_1:sfgRstrntAlwd:2" type="radio" name="svapdxG2_1:sfgRstrntAlwd" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> <div class="firstIndent"> <ol class="romanLC" start="1"> <li> <p class="outputTextNB"> <STRONG>Safeguards Concerning the Use of Restraints.</STRONG> <label id="svapdxG2_1:lblsfgRstrntUsg" for="svapdxG2_1:sfgRstrntUsg" class="outputLabel"> <span id="svapdxG2_1:lbltxtsfgRstrntUsg" class="outputTextNB">Specify the safeguards that the State has established concerning the use of each type of restraint (i.e., personal restraints, drugs used as restraints, mechanical restraints). State laws, regulations, and policies that are referenced are available to CMS upon request through the Medicaid agency or the operating agency (if applicable).</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxG2_1:sfgRstrntUsgChrCntLbl" for="svapdxG2_1:sfgRstrntUsgChrCnt" class="outputLabel"> <span id="svapdxG2_1:sfgRstrntUsgChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxG2_1:sfgRstrntUsgChrCnt" type="text" name="svapdxG2_1:sfgRstrntUsgChrCnt" class="chrCnt" size="6" /><span id="svapdxG2_1:sfgRstrntUsgChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxG2_1:panel_sfgRstrntUsg"><textarea id="svapdxG2_1:sfgRstrntUsg" name="svapdxG2_1:sfgRstrntUsg" class="inputTextarea25" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </li> <li> <p class="outputTextNB"> <strong>State Oversight Responsibility.</strong> <label id="svapdxG2_1:lblsfgRstrntOvrstMth" for="svapdxG2_1:sfgRstrntOvrstMth" class="outputLabel"> <span id="svapdxG2_1:lbltxtsfgRstrntOvrstMth" class="outputTextNB">Specify the State agency (or agencies) responsible for overseeing the use of restraints and ensuring that State safeguards concerning their use are followed and how such oversight is conducted and its frequency:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxG2_1:sfgRstrntOvrstMthChrCntLbl" for="svapdxG2_1:sfgRstrntOvrstMthChrCnt" class="outputLabel"> <span id="svapdxG2_1:sfgRstrntOvrstMthChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxG2_1:sfgRstrntOvrstMthChrCnt" type="text" name="svapdxG2_1:sfgRstrntOvrstMthChrCnt" class="chrCnt" size="6" /><span id="svapdxG2_1:sfgRstrntOvrstMthChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxG2_1:panel_sfgRstrntOvrstMth"><textarea id="svapdxG2_1:sfgRstrntOvrstMth" name="svapdxG2_1:sfgRstrntOvrstMth" class="inputTextarea25" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </li> </ol> </div> </LI> </OL> <H2 id="pageTitle">Appendix G: Participant Safeguards</H2> <H3 id="pageSubTitle">Appendix G-2: Safeguards Concerning Restraints and Restrictive Interventions <SPAN id="pageNumber">(2 of 3)</SPAN></H3> <ol class="alphaLC" start="2"> <LI> <P class="outputTextNB"> <strong>Use of Restrictive Interventions.</strong> <em>(Select one)</em>: </P> <div class="checkboxGroup"><label><input id="svapdxG2_2:sfgResIntAlwd:0" type="radio" name="svapdxG2_2:sfgResIntAlwd" checked="checked" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;The State does not permit or prohibits the use of restrictive interventions</label></div> <div class="firstIndent"> <p class="outputTextNB"> <label id="svapdxG2_2:lblsfgResIntAlwdOvrst" for="svapdxG2_2:sfgResIntAlwdOvrst" class="outputLabel"> <span id="svapdxG2_2:lbltxtsfgResIntAlwdOvrst" class="outputTextNB">Specify the State agency (or agencies) responsible for detecting the unauthorized use of restrictive interventions and how this oversight is conducted and its frequency:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxG2_2:sfgResIntAlwdOvrstChrCntLbl" for="svapdxG2_2:sfgResIntAlwdOvrstChrCnt" class="outputLabel"> <span id="svapdxG2_2:sfgResIntAlwdOvrstChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxG2_2:sfgResIntAlwdOvrstChrCnt" type="text" name="svapdxG2_2:sfgResIntAlwdOvrstChrCnt" class="chrCnt" size="6" /><span id="svapdxG2_2:sfgResIntAlwdOvrstChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxG2_2:panel_sfgResIntAlwdOvrst"><textarea id="svapdxG2_2:sfgResIntAlwdOvrst" name="svapdxG2_2:sfgResIntAlwdOvrst" class="inputTextarea25" onkeyup="Count(this);" readonly="readonly">At any time, a client, community provider or private citizen can report to DSS staff the use of restrictive intervention. Because the use of restrictive intervention is unauthorized and pursuant to Connecticut State PCA Regulation 262-596 (d) the Department reserves the right to terminate any provider who violates any rules or policies of the PCA program. Any use of restrictive intervention would be a violation of program rules resulting in the PCA being terminated and his/her name would be removed from the PCA registry. Employers will also be encouraged and counseled to notify the police if the situation warrants such an intervention. Participants are advised of their rights that prohibits restrictive interventions in the employer guide that is given to each new waiver participant. Effective 4/1/15, the state intends to launch a new core standardized assessment that will be used across all waiver programs. The tool with specifically ask questions to determine if there have been any incidents of restrictive interventions and will be conducted on an annual basis.The care managers will review this with the clients at each reassessment and also encourage the client to contact them directly if there are any concerns that arise between visits.</textarea></span> </div> </div> <div class="checkboxGroup"><label><input id="svapdxG2_2:sfgResIntAlwd:1" type="radio" name="svapdxG2_2:sfgResIntAlwd" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;The use of restrictive interventions is permitted during the course of the delivery of waiver services</label><span class="outputTextNB"> Complete Items G-2-b-i and G-2-b-ii.</span></div> <div class="noShow"><label><input id="svapdxG2_2:sfgResIntAlwd:2" type="radio" name="svapdxG2_2:sfgResIntAlwd" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> <div class="firstIndent"> <OL class="romanLC" start="1"> <li> <p class="outputTextNB"> <strong>Safeguards Concerning the Use of Restrictive Interventions. </strong> <label id="svapdxG2_2:lblsfgResIntUsg" for="svapdxG2_2:sfgResIntUsg" class="outputLabel"> <span id="svapdxG2_2:lbltxtsfgResIntUsg" class="outputTextNB">Specify the safeguards that the State has in effect concerning the use of interventions that restrict participant movement, participant access to other individuals, locations or activities, restrict participant rights or employ aversive methods (not including restraints or seclusion) to modify behavior. State laws, regulations, and policies referenced in the specification are available to CMS upon request through the Medicaid agency or the operating agency.</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxG2_2:sfgResIntUsgChrCntLbl" for="svapdxG2_2:sfgResIntUsgChrCnt" class="outputLabel"> <span id="svapdxG2_2:sfgResIntUsgChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxG2_2:sfgResIntUsgChrCnt" type="text" name="svapdxG2_2:sfgResIntUsgChrCnt" class="chrCnt" size="6" /><span id="svapdxG2_2:sfgResIntUsgChrCntMax" class="chrCnt"> out of 20000</span> </div> <DIV class="inputTextareaWA"> <span id="svapdxG2_2:panel_sfgResIntUsg"><textarea id="svapdxG2_2:sfgResIntUsg" name="svapdxG2_2:sfgResIntUsg" class="inputTextarea25" onkeyup="Count(this);" readonly="readonly"></textarea></span> </DIV> </li> <li> <p class="outputTextNB"> <STRONG>State Oversight Responsibility.</STRONG> <label id="svapdxG2_2:lblsfgResIntOvrstMth" for="svapdxG2_2:sfgResIntOvrstMth" class="outputLabel"> <span id="svapdxG2_2:lbltxtsfgResIntOvrstMth" class="outputTextNB">Specify the State agency (or agencies) responsible for monitoring and overseeing the use of restrictive interventions and how this oversight is conducted and its frequency:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxG2_2:sfgResIntOvrstMthChrCntLbl" for="svapdxG2_2:sfgResIntOvrstMthChrCnt" class="outputLabel"> <span id="svapdxG2_2:sfgResIntOvrstMthChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxG2_2:sfgResIntOvrstMthChrCnt" type="text" name="svapdxG2_2:sfgResIntOvrstMthChrCnt" class="chrCnt" size="6" /><span id="svapdxG2_2:sfgResIntOvrstMthChrCntMax" class="chrCnt"> out of 20000</span> </div> <DIV class="inputTextareaWA"> <span id="svapdxG2_2:panel_sfgResIntOvrstMth"><textarea id="svapdxG2_2:sfgResIntOvrstMth" name="svapdxG2_2:sfgResIntOvrstMth" class="inputTextarea25" onkeyup="Count(this);" readonly="readonly"></textarea></span> </DIV> </li> </OL> </div> </LI> </ol> <H2 id="pageTitle">Appendix G: Participant Safeguards</H2> <H3 id="pageSubTitle">Appendix G-2: Safeguards Concerning Restraints and Restrictive Interventions <SPAN id="pageNumber">(3 of 3)</SPAN></H3> <OL class="alphaLC" start="3"> <LI> <P class="outputTextNB"> <strong>Use of Seclusion.</strong> <em>(Select one)</em>: <span class="paragraph em"> (This section will be blank for waivers submitted before Appendix G-2-c was added to WMS in March 2014, and responses for seclusion will display in Appendix G-2-a combined with information on restraints.) </span> </P> <div class="checkboxGroup"><label><input id="svapdxG2_3:sfgSeclAlwd:0" type="radio" name="svapdxG2_3:sfgSeclAlwd" checked="checked" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;The State does not permit or prohibits the use of seclusion</label></div> <div class="firstIndent"> <p class="outputTextNB"> <label id="svapdxG2_3:lblsfgSeclAlwdOvrst" for="svapdxG2_3:sfgSeclAlwdOvrst" class="outputLabel"> <span id="svapdxG2_3:lbltxtsfgSeclAlwdOvrst" class="outputTextNB">Specify the State agency (or agencies) responsible for detecting the unauthorized use of seclusion and how this oversight is conducted and its frequency:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxG2_3:sfgSeclAlwdOvrstChrCntLbl" for="svapdxG2_3:sfgSeclAlwdOvrstChrCnt" class="outputLabel"> <span id="svapdxG2_3:sfgSeclAlwdOvrstChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxG2_3:sfgSeclAlwdOvrstChrCnt" type="text" name="svapdxG2_3:sfgSeclAlwdOvrstChrCnt" class="chrCnt" size="6" /><span id="svapdxG2_3:sfgSeclAlwdOvrstChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxG2_3:panel_sfgSeclAlwdOvrst"><textarea id="svapdxG2_3:sfgSeclAlwdOvrst" name="svapdxG2_3:sfgSeclAlwdOvrst" class="inputTextarea25" onkeyup="Count(this);" readonly="readonly">At any time, a client, community provider or private citizen can report to DSS staff the use of seclusion. Because the use of seclusion is unauthorized and pursuant to Connecticut State PCA Regulation 262-596 (d) the Department reserves the right to terminate any provider who violates any rules or policies of the PCA program. Any use of seclusion would be a violation of program rules resulting in the provider being terminated. Employers will also be encouraged and counseled to notify the police if the situation warrants such an intervention. Participants are advised of their rights that prohibits the use of seclusion in the employer guide that is given to each new waiver participant. Effective 4/1/15, the state intends to launch a new core standardized assessment that will be used across all waiver programs. The tool with specifically ask questions to determine if there have been any incidents of restrictive interventions and/ or seclusion and will be conducted on an annual basis.The care managers will review this with the clients at each reassessment and also encourage the client to contact them directly if there are any concerns that arise between visits.</textarea></span> </div> </div> <div class="checkboxGroup"><label><input id="svapdxG2_3:sfgSeclAlwd:1" type="radio" name="svapdxG2_3:sfgSeclAlwd" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;The use of seclusion is permitted during the course of the delivery of waiver services</label><span class="outputTextNB">. Complete Items G-2-c-i and G-2-c-ii.</span></div> <div class="noShow"><label><input id="svapdxG2_3:sfgSeclAlwd:2" type="radio" name="svapdxG2_3:sfgSeclAlwd" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> <div class="firstIndent"> <ol class="romanLC" start="1"> <li> <p class="outputTextNB"> <STRONG>Safeguards Concerning the Use of Seclusion.</STRONG> <label id="svapdxG2_3:lblsfgSeclUsg" for="svapdxG2_3:sfgSeclUsg" class="outputLabel"> <span id="svapdxG2_3:lbltxtsfgSeclUsg" class="outputTextNB">Specify the safeguards that the State has established concerning the use of each type of seclusion. State laws, regulations, and policies that are referenced are available to CMS upon request through the Medicaid agency or the operating agency (if applicable).</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxG2_3:sfgSeclUsgChrCntLbl" for="svapdxG2_3:sfgSeclUsgChrCnt" class="outputLabel"> <span id="svapdxG2_3:sfgSeclUsgChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxG2_3:sfgSeclUsgChrCnt" type="text" name="svapdxG2_3:sfgSeclUsgChrCnt" class="chrCnt" size="6" /><span id="svapdxG2_3:sfgSeclUsgChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxG2_3:panel_sfgSeclUsg"><textarea id="svapdxG2_3:sfgSeclUsg" name="svapdxG2_3:sfgSeclUsg" class="inputTextarea25" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </li> <li> <p class="outputTextNB"> <strong>State Oversight Responsibility.</strong> <label id="svapdxG2_3:lblsfgSeclOvrstMth" for="svapdxG2_3:sfgSeclOvrstMth" class="outputLabel"> <span id="svapdxG2_3:lbltxtsfgSeclOvrstMth" class="outputTextNB">Specify the State agency (or agencies) responsible for overseeing the use of seclusion and ensuring that State safeguards concerning their use are followed and how such oversight is conducted and its frequency:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxG2_3:sfgSeclOvrstMthChrCntLbl" for="svapdxG2_3:sfgSeclOvrstMthChrCnt" class="outputLabel"> <span id="svapdxG2_3:sfgSeclOvrstMthChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxG2_3:sfgSeclOvrstMthChrCnt" type="text" name="svapdxG2_3:sfgSeclOvrstMthChrCnt" class="chrCnt" size="6" /><span id="svapdxG2_3:sfgSeclOvrstMthChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxG2_3:panel_sfgSeclOvrstMth"><textarea id="svapdxG2_3:sfgSeclOvrstMth" name="svapdxG2_3:sfgSeclOvrstMth" class="inputTextarea25" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </li> </ol> </div> </LI> </OL> <H2 id="pageTitle">Appendix G: Participant Safeguards</H2> <H3 id="pageSubTitle">Appendix G-3: Medication Management and Administration <SPAN id="pageNumber">(1 of 2)</SPAN></H3> <p class="outputTextNB"> <em> This Appendix must be completed when waiver services are furnished to participants who are served in licensed or unlicensed living arrangements where a provider has round-the-clock responsibility for the health and welfare of residents. The Appendix does not need to be completed when waiver participants are served exclusively in their own personal residences or in the home of a family member. </em> </p> <OL class="alphaLC" start="1"> <LI> <P class="outputTextNB"> <STRONG>Applicability.</STRONG> Select one: </P> <div class="checkboxGroup"> <label><input id="svapdxG3_1:sfgMedsApp:0" type="radio" name="svapdxG3_1:sfgMedsApp" checked="checked" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;No. This Appendix is not applicable</label> <span class="outputTextNB em"> (do not complete the remaining items)</span> </div> <div class="checkboxGroup"> <label><input id="svapdxG3_1:sfgMedsApp:1" type="radio" name="svapdxG3_1:sfgMedsApp" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;Yes. This Appendix applies</label> <span class="outputTextNB em"> (complete the remaining items)</span></div> <div class="noShow"><label><input id="svapdxG3_1:sfgMedsApp:2" type="radio" name="svapdxG3_1:sfgMedsApp" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </LI> <!-- rendered="#{(varFactory.sfgMedsApp == 1)?true:false}"> --> <LI> <p class="outputText"> Medication Management and Follow-Up </p> <p> </p> <OL class="romanLC" start="1"> <LI> <p class="outputTextNB"> <strong>Responsibility.</strong> <label id="svapdxG3_1:lblsfgMedsMonEnt" for="svapdxG3_1:sfgMedsMonEnt" class="outputLabel"> <span id="svapdxG3_1:lbltxtsfgMedsMonEnt" class="outputTextNB"> Specify the entity (or entities) that have ongoing responsibility for monitoring participant medication regimens, the methods for conducting monitoring, and the frequency of monitoring.</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxG3_1:sfgMedsMonEntChrCntLbl" for="svapdxG3_1:sfgMedsMonEntChrCnt" class="outputLabel"> <span id="svapdxG3_1:sfgMedsMonEntChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxG3_1:sfgMedsMonEntChrCnt" type="text" name="svapdxG3_1:sfgMedsMonEntChrCnt" class="chrCnt" size="6" /><span id="svapdxG3_1:sfgMedsMonEntChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxG3_1:panel_sfgMedsMonEnt"><textarea id="svapdxG3_1:sfgMedsMonEnt" name="svapdxG3_1:sfgMedsMonEnt" class="inputTextarea25" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </LI> <LI> <p class="outputTextNB"> <strong>Methods of State Oversight and Follow-Up.</strong> <label id="svapdxG3_1:lblsfgMedsOvrstMth" for="svapdxG3_1:sfgMedsOvrstMth" class="outputLabel"> <span id="svapdxG3_1:lbltxtsfgMedsOvrstMth" class="outputTextNB"> Describe: (a) the method(s) that the State uses to ensure that participant medications are managed appropriately, including: (a) the identification of potentially harmful practices (e.g., the concurrent use of contraindicated medications); (b) the method(s) for following up on potentially harmful practices; and, (c) the State agency (or agencies) that is responsible for follow-up and oversight.</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxG3_1:sfgMedsOvrstMthChrCntLbl" for="svapdxG3_1:sfgMedsOvrstMthChrCnt" class="outputLabel"> <span id="svapdxG3_1:sfgMedsOvrstMthChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxG3_1:sfgMedsOvrstMthChrCnt" type="text" name="svapdxG3_1:sfgMedsOvrstMthChrCnt" class="chrCnt" size="6" /><span id="svapdxG3_1:sfgMedsOvrstMthChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxG3_1:panel_sfgMedsOvrstMth"><textarea id="svapdxG3_1:sfgMedsOvrstMth" name="svapdxG3_1:sfgMedsOvrstMth" class="inputTextarea25" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </LI> </OL> </LI> </OL> <H2 id="pageTitle">Appendix G: Participant Safeguards</H2> <H3 id="pageSubTitle">Appendix G-3: Medication Management and Administration <SPAN id="pageNumber">(2 of 2)</SPAN></H3> <OL class="alphaLC" start="3"> <LI> <p class="outputText"> Medication Administration by Waiver Providers </p> <div class="firstIndent pph"> <span id="svapdxG3_2:txt_apdxG3_2No" class="underline pph outputText">Answers provided in G-3-a indicate you do not need to complete this section</span> </div> <!-- rendered="#{(varFactory.sfgMedsApp == 1)?true:false}"> --> <OL class="romanLC" start="1"> <LI> <p class="outputTextNB"> <strong>Provider Administration of Medications.</strong> <em>Select one:</em> </p> <div class="checkboxGroup"> <label><input id="svapdxG3_2:sfgMedsByPrvdr:0" type="radio" name="svapdxG3_2:sfgMedsByPrvdr" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;Not applicable.</label> <span class="outputTextNB em">(do not complete the remaining items)</span> </div> <div class="checkboxGroup"> <label><input id="svapdxG3_2:sfgMedsByPrvdr:1" type="radio" name="svapdxG3_2:sfgMedsByPrvdr" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;Waiver providers are responsible for the administration of medications to waiver participants who cannot self-administer and/or have responsibility to oversee participant self-administration of medications.</label> <span class="outputTextNB em">(complete the remaining items)</span> </div> <div class="noShow"> <label><input id="svapdxG3_2:sfgMedsByPrvdr:2" type="radio" name="svapdxG3_2:sfgMedsByPrvdr" checked="checked" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label> </div> <div class="firstIndent pph"> </div> </LI> <!--rendered="#{(varFactory.sfgMedsByPrvdr == 1)?true:false}"> --> <LI> <p class="outputTextNB"> <strong>State Policy.</strong> <label id="svapdxG3_2:lblsfgMedsByPrvdrPolt" for="svapdxG3_2:sfgMedsByPrvdrPol" class="outputLabel"> <span id="svapdxG3_2:lbltxtsfgMedsByPrvdrPol" class="outputTextNB"> Summarize the State policies that apply to the administration of medications by waiver providers or waiver provider responsibilities when participants self-administer medications, including (if applicable) policies concerning medication administration by non-medical waiver provider personnel. State laws, regulations, and policies referenced in the specification are available to CMS upon request through the Medicaid agency or the operating agency (if applicable).</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxG3_2:sfgMedsByPrvdrPolChrCntLbl" for="svapdxG3_2:sfgMedsByPrvdrPolChrCnt" class="outputLabel"> <span id="svapdxG3_2:sfgMedsByPrvdrPolChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxG3_2:sfgMedsByPrvdrPolChrCnt" type="text" name="svapdxG3_2:sfgMedsByPrvdrPolChrCnt" class="chrCnt" size="6" /><span id="svapdxG3_2:sfgMedsByPrvdrPolChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxG3_2:panel_sfgMedsByPrvdrPol"><textarea id="svapdxG3_2:sfgMedsByPrvdrPol" name="svapdxG3_2:sfgMedsByPrvdrPol" class="inputTextarea25" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </LI> <LI> <p class="outputTextNB"> <STRONG>Medication Error Reporting.</STRONG> <em>Select one of the following:</em> </p> <!-- CHECKBOX C iii - 0 --> <div class="checkboxGroup"><label><input id="svapdxG3_2:sfgMedsErrTrkType:0" type="radio" name="svapdxG3_2:sfgMedsErrTrkType" value="0" onclick="return callSave(this, event);" title="Medication Error Reporting." disabled="disabled" />&#160;Providers that are responsible for medication administration are required to both record and report medication errors to a State agency (or agencies). </label></div> <div class="firstIndent"> <!-- rendered="#{(varFactory.sfgMedsErrTrkType == 0)?true:false}"> --> <div class="outputTextNB"> <EM>Complete the following three items:</EM> </div> <p class="outputTextNB"> <label id="svapdxG3_2:lblsfgMedsErrStAg" for="svapdxG3_2:sfgMedsErrStAg" class="outputLabel"> <span id="svapdxG3_2:lbltxtsfgMedsErrStAg" class="outputTextNB">(a) Specify State agency (or agencies) to which errors are reported:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxG3_2:sfgMedsErrStAgChrCntLbl" for="svapdxG3_2:sfgMedsErrStAgChrCnt" class="outputLabel"> <span id="svapdxG3_2:sfgMedsErrStAgChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxG3_2:sfgMedsErrStAgChrCnt" type="text" name="svapdxG3_2:sfgMedsErrStAgChrCnt" class="chrCnt" size="6" /><span id="svapdxG3_2:sfgMedsErrStAgChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxG3_2:panel_sfgMedsErrStAg"><textarea id="svapdxG3_2:sfgMedsErrStAg" name="svapdxG3_2:sfgMedsErrStAg" class="inputTextarea25" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> <p class="outputTextNB"> <label id="svapdxG3_2:lblsfgMedsErrRcdDscr" for="svapdxG3_2:sfgMedsErrRcdDscr" class="outputLabel"> <span id="svapdxG3_2:lbltxtsfgMedsErrRcdDscr1" class="outputTextNB">(b) Specify the types of medication errors that providers are required to </span><span id="svapdxG3_2:lbltxtsfgMedsErrRcdDscr2" class="outputTextNB em"> record:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxG3_2:sfgMedsErrRcdDscrChrCntLbl" for="svapdxG3_2:sfgMedsErrRcdDscrChrCnt" class="outputLabel"> <span id="svapdxG3_2:sfgMedsErrRcdDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxG3_2:sfgMedsErrRcdDscrChrCnt" type="text" name="svapdxG3_2:sfgMedsErrRcdDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxG3_2:sfgMedsErrRcdDscrChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxG3_2:panel_sfgMedsErrRcdDscr"><textarea id="svapdxG3_2:sfgMedsErrRcdDscr" name="svapdxG3_2:sfgMedsErrRcdDscr" class="inputTextarea25" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> <p class="outputTextNB"> <label id="svapdxG3_2:lblsfgMedsErrRptDscr" for="svapdxG3_2:sfgMedsErrRptDscr" class="outputLabel"> <span id="svapdxG3_2:lbltxtsfgMedsErrRptDscr1" class="outputTextNB">(c) Specify the types of medication errors that providers must </span><span id="svapdxG3_2:lbltxtsfgMedsErrRptDscr2" class="outputTextNB em"> report</span><span id="svapdxG3_2:lbltxtsfgMedsErrRptDscr3" class="outputTextNB"> to the State:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxG3_2:sfgMedsErrRptDscrChrCntLbl" for="svapdxG3_2:sfgMedsErrRptDscrChrCnt" class="outputLabel"> <span id="svapdxG3_2:sfgMedsErrRptDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxG3_2:sfgMedsErrRptDscrChrCnt" type="text" name="svapdxG3_2:sfgMedsErrRptDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxG3_2:sfgMedsErrRptDscrChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxG3_2:panel_sfgMedsErrRptDscr"><textarea id="svapdxG3_2:sfgMedsErrRptDscr" name="svapdxG3_2:sfgMedsErrRptDscr" class="inputTextarea25" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <!-- CHECKBOX C iii - 1 --> <div class="checkboxGroup"> <label><input id="svapdxG3_2:sfgMedsErrTrkType:1" type="radio" name="svapdxG3_2:sfgMedsErrTrkType" value="1" onclick="return callSave(this, event);" title="Medication Error Reporting." disabled="disabled" />&#160;Providers responsible for medication administration are required to record medication errors but make information about medication errors available only when requested by the State.</label> </div> <div class="firstIndent"> <!-- rendered="#{(varFactory.sfgMedsErrTrkType == 1)?true:false}"> --> <p> <label id="svapdxG3_2:lblsfgMedsErrRcdOnlyDscr" for="svapdxG3_2:sfgMedsErrRcdOnlyDscr" class="outputLabel"> <span id="svapdxG3_2:lbltxtsfgMedsErrRcdOnlyDscr" class="outputTextNB">Specify the types of medication errors that providers are required to record:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxG3_2:sfgMedsErrRcdOnlyDscrChrCntLbl" for="svapdxG3_2:sfgMedsErrRcdOnlyDscrChrCnt" class="outputLabel"> <span id="svapdxG3_2:sfgMedsErrRcdOnlyDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxG3_2:sfgMedsErrRcdOnlyDscrChrCnt" type="text" name="svapdxG3_2:sfgMedsErrRcdOnlyDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxG3_2:sfgMedsErrRcdOnlyDscrChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxG3_2:panel_sfgMedsErrRcdOnlyDscr"><textarea id="svapdxG3_2:sfgMedsErrRcdOnlyDscr" name="svapdxG3_2:sfgMedsErrRcdOnlyDscr" class="inputTextarea25" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="noShow"><label><input id="svapdxG3_2:sfgMedsErrTrkType:2" type="radio" name="svapdxG3_2:sfgMedsErrTrkType" checked="checked" value="99" onclick="return callSave(this, event);" title="Medication Error Reporting." disabled="disabled" />&#160;not selected</label></div> </LI> <LI> <p class="outputTextNB"> <strong>State Oversight Responsibility.</strong> <label id="svapdxG3_2:lblsfgMedsErrOvrstMth" for="svapdxG3_2:sfgMedsErrOvrstMth" class="outputLabel"> <span id="svapdxG3_2:lbltxtsfgMedsErrOvrstMth" class="outputTextNB">Specify the State agency (or agencies) responsible for monitoring the performance of waiver providers in the administration of medications to waiver participants and how monitoring is performed and its frequency.</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxG3_2:sfgMedsErrOvrstMthChrCntLbl" for="svapdxG3_2:sfgMedsErrOvrstMthChrCnt" class="outputLabel"> <span id="svapdxG3_2:sfgMedsErrOvrstMthChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxG3_2:sfgMedsErrOvrstMthChrCnt" type="text" name="svapdxG3_2:sfgMedsErrOvrstMthChrCnt" class="chrCnt" size="6" /><span id="svapdxG3_2:sfgMedsErrOvrstMthChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxG3_2:panel_sfgMedsErrOvrstMth"><textarea id="svapdxG3_2:sfgMedsErrOvrstMth" name="svapdxG3_2:sfgMedsErrOvrstMth" class="inputTextarea25" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </LI> </OL> </LI> </OL> <H2 id="pageTitle">Appendix G: Participant Safeguards</H2> <H3 id="pageSubTitle">Quality Improvement: Health and Welfare</H3> <div class="paragraph"> <span class="outputTextNB em"> As a distinct component of the State’s quality improvement strategy, provide information in the following fields to detail the State’s methods for discovery and remediation. </span> </div> <ol class="alphaLC" id="AQa" start="1" > <li style="margin-top: 1em;"> <div class="paragraph"> <span class="outputText">Methods for Discovery: Health and Welfare</span> </div> <div class="paragraph em"> <span class="outputText">The state demonstrates it has designed and implemented an effective system for assuring waiver participant health and welfare. </span> <span class="outputTextNB">(For waiver actions submitted before June 1, 2014, this assurance read "The State, on an ongoing basis, identifies, addresses, and seeks to prevent the occurrence of abuse, neglect and exploitation.")</span> </div> <ol class="romanLC" id="GQai" start="1"> <li> <!-- a.i. --> <div>Sub-Assurances:</div> <ol class="alphaLC" start="1"> <li style="padding-bottom: 1em;"> <!-- a.i.a --> <div> <p> <span id="svapdxGQ_1:aiaSA" class="outputText em">Sub-assurance: The state demonstrates on an ongoing basis that it identifies, addresses and seeks to prevent instancesof abuse, neglect, exploitation and unexplained death. </span><span id="svapdxGQ_1:aiaSA_note" class="outputTextNB em"> (Performance measures in this sub-assurance include all Appendix G performance measures for waiver actions submitted before June 1, 2014.)</span> </p> <p class="pph"> <span class="outputText">Performance Measures</span> </p> <p class="pph"> <span id="svapdxGQ_1:aiaPMInfo1" class="outputTextNB em">For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.</span> </p> <p class="pph"> <span id="svapdxGQ_1:aiaPMInstr1" class="outputTextNB em ul">For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.</span> </p> </div> <div class=""> <table id="svapdxGQ_1:dtPMPrntHW" class="nstTableX" summary="Expanded dynamic table for services" ><tbody > <tr ><td > <div style="padding-bottom: 1.5em; width:90%;" > <span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:pmName" class="inputTextPct">Number and Percent of all care plans will identify an emergency back up plan. Numerator = all care plans will identify an emergency back up plan. Denominator = all care plans shall include a emergency back up plan.</span> </div> </div> <table id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource" style="width: 90%" class="nstTableX" border="0" cellpadding="2" cellspacing="0" summary="dynamic table for Performance Measure Data Sources" ><tbody > <tr ><td ><label id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Record reviews, on-site</span><div id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct"></span></div></div></div><table id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:pmPnlGrdChkboxSet" class="nstTableX" border="1" cellpadding="3" cellspacing="0" style="vertical-align: top; margin-bottom: 1.5em;"> <tbody> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsSaPct" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaLtPct" class="outputText">Less than 100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsFdCo" checked="checked" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsSaOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:dtDataSource:0:dssa6"></span></td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <div style="padding: 1em 0 1em 0;"> </div> <div> <span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:pmDAA" class="outputText" style="margin-top: 1.5em;">Data Aggregation and Analysis:</span> </div> <table id="pmPnlGrdChkboxSet" class="nstTableX" id="pmPnlGrdChkboxSet"cellpadding="3" cellspacing="0" border="1" style="vertical-align: top; width: 85%;"> <THEAD><tr align="left" valign="top"> <th id="rp" class="third"> <span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:txtPMfom2" class="outputTextNB em">(check each that applies):</span> </th> </tr></THEAD> <TBODY valign="top" align="left"> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:pmDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:pmDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:pmDaFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:pmDaRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:pmDaRpOthDsc" name="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:pmDaRpOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:pmDaFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:txtlbl_pmDaFdAn" class="outputText">Annually</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:pmDaFdCo" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:txtlblpmDaFdCo" class="outputText">Continuously and Ongoing</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup" > <input id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:pmDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:pmDaFdOtDsc" name="svapdxGQ_1:dtPMPrntHW:0:svQmPerfMeas:pmDaFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> </tr> </TBODY> </table> <div> </div> </td> </tr> <tr ><td > <div style="padding-bottom: 1.5em; width:90%;" > <span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:pmName" class="inputTextPct">Number and percent of individual employees will have a criminal background checks completed prior to employment Numerator = all PCA and private employees will have a criminal background check completed prior to employment. Denominator = all individual employees have completed a criminal background check.</span> </div> </div> <table id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource" style="width: 90%" class="nstTableX" border="0" cellpadding="2" cellspacing="0" summary="dynamic table for Performance Measure Data Sources" ><tbody > <tr ><td ><label id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Other</span><div id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct">Ad hoc reports</span></div></div></div><table id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:pmPnlGrdChkboxSet" class="nstTableX" border="1" cellpadding="3" cellspacing="0" style="vertical-align: top; margin-bottom: 1.5em;"> <tbody> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsRpSma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsSaPct" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaLtPct" class="outputText">Less than 100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="inputTextarea" readonly="readonly">fiscal intermediary</textarea></span></div></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsFdCo" checked="checked" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsSaOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:dtDataSource:0:dssa6"></span></td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <div style="padding: 1em 0 1em 0;"> </div> <div> <span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:pmDAA" class="outputText" style="margin-top: 1.5em;">Data Aggregation and Analysis:</span> </div> <table id="pmPnlGrdChkboxSet" class="nstTableX" id="pmPnlGrdChkboxSet"cellpadding="3" cellspacing="0" border="1" style="vertical-align: top; width: 85%;"> <THEAD><tr align="left" valign="top"> <th id="rp" class="third"> <span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:txtPMfom2" class="outputTextNB em">(check each that applies):</span> </th> </tr></THEAD> <TBODY valign="top" align="left"> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:pmDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:pmDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:pmDaFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:pmDaRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:pmDaRpOthDsc" name="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:pmDaRpOthDsc" class="inputTextarea" readonly="readonly">fiscal intermediary</textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:pmDaFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:txtlbl_pmDaFdAn" class="outputText">Annually</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:pmDaFdCo" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:txtlblpmDaFdCo" class="outputText">Continuously and Ongoing</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup" > <input id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:pmDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:pmDaFdOtDsc" name="svapdxGQ_1:dtPMPrntHW:1:svQmPerfMeas:pmDaFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> </tr> </TBODY> </table> <div> </div> </td> </tr> <tr ><td > <div style="padding-bottom: 1.5em; width:90%;" > <span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:pmName" class="inputTextPct">Number and percent of participants and/or legal guardian who receive information about how to report abuse, neglect and exploitation. Numerator = participants and/or legal guardian will receive information about how to report abuse, neglect and exploitation. Denominator = number of reports received from participants and/or legal guardian reporting abuse, neglect and exploitation.</span> </div> </div> <table id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource" style="width: 90%" class="nstTableX" border="0" cellpadding="2" cellspacing="0" summary="dynamic table for Performance Measure Data Sources" ><tbody > <tr ><td ><label id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Record reviews, on-site</span><div id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct"></span></div></div></div><table id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:pmPnlGrdChkboxSet" class="nstTableX" border="1" cellpadding="3" cellspacing="0" style="vertical-align: top; margin-bottom: 1.5em;"> <tbody> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsSaPct" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaLtPct" class="outputText">Less than 100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsFdCo" checked="checked" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsSaOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:dtDataSource:0:dssa6"></span></td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <div style="padding: 1em 0 1em 0;"> </div> <div> <span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:pmDAA" class="outputText" style="margin-top: 1.5em;">Data Aggregation and Analysis:</span> </div> <table id="pmPnlGrdChkboxSet" class="nstTableX" id="pmPnlGrdChkboxSet"cellpadding="3" cellspacing="0" border="1" style="vertical-align: top; width: 85%;"> <THEAD><tr align="left" valign="top"> <th id="rp" class="third"> <span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:txtPMfom2" class="outputTextNB em">(check each that applies):</span> </th> </tr></THEAD> <TBODY valign="top" align="left"> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:pmDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:pmDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:pmDaFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:pmDaRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:pmDaRpOthDsc" name="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:pmDaRpOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:pmDaFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:txtlbl_pmDaFdAn" class="outputText">Annually</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:pmDaFdCo" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:txtlblpmDaFdCo" class="outputText">Continuously and Ongoing</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup" > <input id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:pmDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:pmDaFdOtDsc" name="svapdxGQ_1:dtPMPrntHW:2:svQmPerfMeas:pmDaFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> </tr> </TBODY> </table> <div> </div> </td> </tr> </tbody> </table> </div> </li> <li style="padding-bottom: 1em;"> <!-- a.i.b --> <div> <p> <span id="svapdxGQ_1:aibSA" class="outputText em">Sub-assurance: The state demonstrates that an incident management system is in place that effectively resolves those incidents and prevents further similar incidents to the extent possible.</span> </p> <p class="pph"> <span class="outputText">Performance Measures</span> </p> <p class="pph"> <span id="svapdxGQ_1:aibPMInfo1" class="outputTextNB em">For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.</span> </p> <p class="pph"> <span id="svapdxGQ_1:aibPMInstr1" class="outputTextNB em ul">For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.</span> </p> </div> <div class=""> <table id="svapdxGQ_1:dtPMPrntHWB" class="nstTableX" summary="Expanded dynamic table for services" ><tbody > <tr ><td > <div style="padding-bottom: 1.5em; width:90%;" > <span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:pmName" class="inputTextPct">Number and percent of serious incident reports that are reported to the department unit within 48 hours as required by the waiver. Numerator = reports of serious incident reports that are reported within 48 hours as required by the waiver. Denominator= all incident reports are received.</span> </div> </div> <table id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource" style="width: 90%" class="nstTableX" border="0" cellpadding="2" cellspacing="0" summary="dynamic table for Performance Measure Data Sources" ><tbody > <tr ><td ><label id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Reports to State Medicaid Agency on delegated</span><div id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct">Critical Incident Reports</span></div></div></div><table id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:pmPnlGrdChkboxSet" class="nstTableX" border="1" cellpadding="3" cellspacing="0" style="vertical-align: top; margin-bottom: 1.5em;"> <tbody> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsRpSma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsSaPct" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaLtPct" class="outputText">Less than 100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="inputTextarea" readonly="readonly">Fiscal intermediary and provider agencies</textarea></span></div></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsFdCo" checked="checked" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsSaOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:dtDataSource:0:dssa6"></span></td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <div style="padding: 1em 0 1em 0;"> </div> <div> <span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:pmDAA" class="outputText" style="margin-top: 1.5em;">Data Aggregation and Analysis:</span> </div> <table id="pmPnlGrdChkboxSet" class="nstTableX" id="pmPnlGrdChkboxSet"cellpadding="3" cellspacing="0" border="1" style="vertical-align: top; width: 85%;"> <THEAD><tr align="left" valign="top"> <th id="rp" class="third"> <span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:txtPMfom2" class="outputTextNB em">(check each that applies):</span> </th> </tr></THEAD> <TBODY valign="top" align="left"> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:pmDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:pmDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:pmDaFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:pmDaRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:pmDaRpOthDsc" name="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:pmDaRpOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:pmDaFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:txtlbl_pmDaFdAn" class="outputText">Annually</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:pmDaFdCo" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:txtlblpmDaFdCo" class="outputText">Continuously and Ongoing</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup" > <input id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:pmDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:pmDaFdOtDsc" name="svapdxGQ_1:dtPMPrntHWB:0:svQmPerfMeas:pmDaFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> </tr> </TBODY> </table> <div> </div> </td> </tr> <tr ><td > <div style="padding-bottom: 1.5em; width:90%;" > <span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:pmName" class="inputTextPct">The number and percent of critical incident requiring review/investigation where the department adhered to the follow up methods as specified in the approved waiver. Numerator is critical incidents reviewed adhering to methods in the waiver and the denominator is the total number of critical incidents reviewed</span> </div> </div> <table id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource" style="width: 90%" class="nstTableX" border="0" cellpadding="2" cellspacing="0" summary="dynamic table for Performance Measure Data Sources" ><tbody > <tr ><td ><label id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Critical events and incident reports</span><div id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct"></span></div></div></div><table id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:pmPnlGrdChkboxSet" class="nstTableX" border="1" cellpadding="3" cellspacing="0" style="vertical-align: top; margin-bottom: 1.5em;"> <tbody> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsSaPct" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaLtPct" class="outputText">Less than 100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="inputTextarea" readonly="readonly">reports can be generated by care managers</textarea></span></div></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsFdCo" checked="checked" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsSaOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:dtDataSource:0:dssa6"></span></td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <div style="padding: 1em 0 1em 0;"> </div> <div> <span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:pmDAA" class="outputText" style="margin-top: 1.5em;">Data Aggregation and Analysis:</span> </div> <table id="pmPnlGrdChkboxSet" class="nstTableX" id="pmPnlGrdChkboxSet"cellpadding="3" cellspacing="0" border="1" style="vertical-align: top; width: 85%;"> <THEAD><tr align="left" valign="top"> <th id="rp" class="third"> <span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:txtPMfom2" class="outputTextNB em">(check each that applies):</span> </th> </tr></THEAD> <TBODY valign="top" align="left"> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:pmDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:pmDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:pmDaFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:pmDaRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:pmDaRpOthDsc" name="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:pmDaRpOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:pmDaFdAn" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:txtlbl_pmDaFdAn" class="outputText">Annually</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:pmDaFdCo" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:txtlblpmDaFdCo" class="outputText">Continuously and Ongoing</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup" > <input id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:pmDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:pmDaFdOtDsc" name="svapdxGQ_1:dtPMPrntHWB:1:svQmPerfMeas:pmDaFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> </tr> </TBODY> </table> <div> </div> </td> </tr> </tbody> </table> </div> </li> <li style="padding-bottom: 1em;"> <!-- a.i.c --> <div> <p> <span id="svapdxGQ_1:aicSA" class="outputText em">Sub-assurance: The state policies and procedures for the use or prohibition of restrictive interventions (including restraints and seclusion) are followed.</span> </p> <p class="pph"> <span class="outputText">Performance Measures</span> </p> <p class="pph"> <span id="svapdxGQ_1:aicPMInfo1" class="outputTextNB em">For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.</span> </p> <p class="pph"> <span id="svapdxGQ_1:aicPMInstr1" class="outputTextNB em ul">For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.</span> </p> </div> <div class=""> <table id="svapdxGQ_1:dtPMPrntHWC" class="nstTableX" summary="Expanded dynamic table for services" ><tbody > <tr ><td > <div style="padding-bottom: 1.5em; width:90%;" > <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:pmName" class="inputTextPct">Number and percent of reports of restrictive interventions that were investigated and remediated in accordance with the prohibition per waiver policy. Numerator= reports reviewed in accordance with policy Denominator= total number of reports</span> </div> </div> <table id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource" style="width: 90%" class="nstTableX" border="0" cellpadding="2" cellspacing="0" summary="dynamic table for Performance Measure Data Sources" ><tbody > <tr ><td ><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Critical events and incident reports</span><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct"></span></div></div></div><table id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:pmPnlGrdChkboxSet" class="nstTableX" border="1" cellpadding="3" cellspacing="0" style="vertical-align: top; margin-bottom: 1.5em;"> <tbody> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsSaPct" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaLtPct" class="outputText">Less than 100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsFdCo" checked="checked" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsSaOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:0:dssa6"></span></td> </tr> </tbody> </table> </td> </tr> <tr ><td ><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsTypeLbl" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsType"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsTypeDDDiv"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsType" class="inputText">Other</span><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsOtherNamelblDiv"><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsNameLbl" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsName"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:panel_dsName"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsName" class="inputTextPct">Data from the questions in the core standardized assessment</span></div></div></div><table id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:pmPnlGrdChkboxSet" class="nstTableX" border="1" cellpadding="3" cellspacing="0" style="vertical-align: top; margin-bottom: 1.5em;"> <tbody> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsrp1"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:PMrp1div" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsRpSma" type="checkbox" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsRpSma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:lbl_dsRpSma" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsRpSma" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsfom1"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsFdWkdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsFdWk" type="checkbox" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:lbl_dsFdWk" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsFdWk" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dssa1"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsSaPctdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsSaPct" type="checkbox" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsSaPct" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:lbl_dsSaPct" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsSaPct" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsrp2"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsRpOpadiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsRpOpa" type="checkbox" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:lbl_dsRpOpa" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsRpOpa" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsfom2"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsFdModiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsFdMo" type="checkbox" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:lbl_dsFdMo" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsFdMo" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dssa2"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsSaLtPct" type="checkbox" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsSaLtPct" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:lbl_dsSaLtPct" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsSaLtPct" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsSaLtPct" class="outputText">Less than 100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsrp3"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsRpCmadiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsRpCma" type="checkbox" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:lbl_dsRpCma" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsRpCma" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsfom3"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsFdQudiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsFdQu" type="checkbox" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:lbl_dsFdQu" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsFdQu" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dssa3" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsSaRsdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsSaRs" type="checkbox" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:lbl_dsSaRs" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsSaRs" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:lbl2_dsSaRsDsc" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsSaRsDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:panel_dsSaRsDsc"><textarea id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsSaRsDsc" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsSaRsDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsrp4"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsRpOthdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsRpOth" type="checkbox" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:lbl_dsRpOth" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsRpOth" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:lbl2_dsRpOthDsc" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsRpOthDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:panel_dsRpOthDsc"><textarea id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsRpOthDsc" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsRpOthDsc" class="inputTextarea" readonly="readonly">Care managers who complete assessment/reassessment visits</textarea></span></div></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsfom4"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsFdAndiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsFdAn" type="checkbox" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsFdAn" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:lbl_dsFdAn" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsFdAn" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dssa4" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsSaStrdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsSaStr" type="checkbox" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:lbl_dsSaStr" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsSaStr" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:lbl2_dsSaStrDsc" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsSaStrDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:panel_dsSaStrDsc"><textarea id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsSaStrDsc" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsSaStrDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsrp5"></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsfom5"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsFdCodiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsFdCo" type="checkbox" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsFdCo" checked="checked" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:lbl_dsFdCo" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsFdCo" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dssa5" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsSaOthdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsSaOth" type="checkbox" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsSaOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:lbl_dsSaOth" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsSaOth" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:lbl2_dsSaOthDsc" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsSaOthDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:panel_dsSaOthDsc"><textarea id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsSaOthDsc" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsSaOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsrp6"></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsfom6"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsFdOtdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsFdOt" type="checkbox" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:lbl_dsFdOt" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsFdOt" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:lbl2_dsFdOtDsc" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsFdOtDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:panel_dsFdOtDsc"><textarea id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsFdOtDsc" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:dtDataSource:1:dssa6"></span></td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <div style="padding: 1em 0 1em 0;"> </div> <div> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:pmDAA" class="outputText" style="margin-top: 1.5em;">Data Aggregation and Analysis:</span> </div> <table id="pmPnlGrdChkboxSet" class="nstTableX" id="pmPnlGrdChkboxSet"cellpadding="3" cellspacing="0" border="1" style="vertical-align: top; width: 85%;"> <THEAD><tr align="left" valign="top"> <th id="rp" class="third"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:txtPMfom2" class="outputTextNB em">(check each that applies):</span> </th> </tr></THEAD> <TBODY valign="top" align="left"> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:pmDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:pmDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:pmDaFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:pmDaRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:pmDaRpOthDsc" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:pmDaRpOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:pmDaFdAn" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:txtlbl_pmDaFdAn" class="outputText">Annually</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:pmDaFdCo" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:txtlblpmDaFdCo" class="outputText">Continuously and Ongoing</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup" > <input id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:pmDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:pmDaFdOtDsc" name="svapdxGQ_1:dtPMPrntHWC:0:svQmPerfMeas:pmDaFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> </tr> </TBODY> </table> <div> </div> </td> </tr> </tbody> </table> </div> </li> <li style="padding-bottom: 1em;"> <!-- a.i.d --> <div> <p> <span id="svapdxGQ_1:aidSA" class="outputText em">Sub-assurance: The state establishes overall health care standards and monitors those standards based on the responsibility of the service provider as stated in the approved waiver.</span> </p> <p class="pph"> <span class="outputText">Performance Measures</span> </p> <p class="pph"> <span id="svapdxGQ_1:aidPMInfo1" class="outputTextNB em">For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.</span> </p> <p class="pph"> <span id="svapdxGQ_1:aidPMInstr1" class="outputTextNB em ul">For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.</span> </p> </div> <div class=""> <table id="svapdxGQ_1:dtPMPrntHWD" class="nstTableX" summary="Expanded dynamic table for services" ><tbody > <tr ><td > <div style="padding-bottom: 1.5em; width:90%;" > <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:pmName" class="inputTextPct">Number and percent of waiver participants who receive age appropriate preventive health care. Numerator is the number of participants who receive preventive care and the denominator is the number of waiver participants</span> </div> </div> <table id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource" style="width: 90%" class="nstTableX" border="0" cellpadding="2" cellspacing="0" summary="dynamic table for Performance Measure Data Sources" ><tbody > <tr ><td ><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Other</span><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct">Core standardized assessment conducted by care managers</span></div></div></div><table id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:pmPnlGrdChkboxSet" class="nstTableX" border="1" cellpadding="3" cellspacing="0" style="vertical-align: top; margin-bottom: 1.5em;"> <tbody> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsRpSma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsSaPct" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaLtPct" class="outputText">Less than 100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="inputTextarea" readonly="readonly">Care managers completing assessments/reassessments</textarea></span></div></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsFdAn" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsFdCo" checked="checked" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsSaOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:0:dssa6"></span></td> </tr> </tbody> </table> </td> </tr> <tr ><td ><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsTypeLbl" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsType"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsTypeDDDiv"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsType" class="inputText">Other</span><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsOtherNamelblDiv"><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsNameLbl" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsName"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:panel_dsName"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsName" class="inputTextPct">Paid claims data for preventive care procedure codes</span></div></div></div><table id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:pmPnlGrdChkboxSet" class="nstTableX" border="1" cellpadding="3" cellspacing="0" style="vertical-align: top; margin-bottom: 1.5em;"> <tbody> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsrp1"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:PMrp1div" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsRpSma" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:lbl_dsRpSma" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsRpSma" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsfom1"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsFdWkdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsFdWk" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:lbl_dsFdWk" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsFdWk" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dssa1"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsSaPctdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsSaPct" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsSaPct" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:lbl_dsSaPct" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsSaPct" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsrp2"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsRpOpadiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsRpOpa" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:lbl_dsRpOpa" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsRpOpa" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsfom2"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsFdModiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsFdMo" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:lbl_dsFdMo" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsFdMo" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dssa2"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsSaLtPct" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsSaLtPct" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:lbl_dsSaLtPct" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsSaLtPct" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsSaLtPct" class="outputText">Less than 100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsrp3"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsRpCmadiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsRpCma" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:lbl_dsRpCma" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsRpCma" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsfom3"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsFdQudiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsFdQu" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:lbl_dsFdQu" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsFdQu" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dssa3" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsSaRsdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsSaRs" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:lbl_dsSaRs" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsSaRs" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:lbl2_dsSaRsDsc" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsSaRsDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:panel_dsSaRsDsc"><textarea id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsSaRsDsc" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsSaRsDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsrp4"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsRpOthdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsRpOth" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:lbl_dsRpOth" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsRpOth" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:lbl2_dsRpOthDsc" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsRpOthDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:panel_dsRpOthDsc"><textarea id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsRpOthDsc" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsRpOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsfom4"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsFdAndiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsFdAn" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:lbl_dsFdAn" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsFdAn" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dssa4" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsSaStrdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsSaStr" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:lbl_dsSaStr" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsSaStr" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:lbl2_dsSaStrDsc" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsSaStrDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:panel_dsSaStrDsc"><textarea id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsSaStrDsc" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsSaStrDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsrp5"></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsfom5"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsFdCodiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsFdCo" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsFdCo" checked="checked" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:lbl_dsFdCo" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsFdCo" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dssa5" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsSaOthdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsSaOth" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsSaOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:lbl_dsSaOth" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsSaOth" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:lbl2_dsSaOthDsc" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsSaOthDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:panel_dsSaOthDsc"><textarea id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsSaOthDsc" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsSaOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsrp6"></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsfom6"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsFdOtdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsFdOt" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:lbl_dsFdOt" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsFdOt" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:lbl2_dsFdOtDsc" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsFdOtDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:panel_dsFdOtDsc"><textarea id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsFdOtDsc" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:dtDataSource:1:dssa6"></span></td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <div style="padding: 1em 0 1em 0;"> </div> <div> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:pmDAA" class="outputText" style="margin-top: 1.5em;">Data Aggregation and Analysis:</span> </div> <table id="pmPnlGrdChkboxSet" class="nstTableX" id="pmPnlGrdChkboxSet"cellpadding="3" cellspacing="0" border="1" style="vertical-align: top; width: 85%;"> <THEAD><tr align="left" valign="top"> <th id="rp" class="third"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:txtPMfom2" class="outputTextNB em">(check each that applies):</span> </th> </tr></THEAD> <TBODY valign="top" align="left"> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:pmDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:pmDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:pmDaFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:pmDaRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:pmDaRpOthDsc" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:pmDaRpOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:pmDaFdAn" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:txtlbl_pmDaFdAn" class="outputText">Annually</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:pmDaFdCo" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:txtlblpmDaFdCo" class="outputText">Continuously and Ongoing</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup" > <input id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:pmDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:pmDaFdOtDsc" name="svapdxGQ_1:dtPMPrntHWD:0:svQmPerfMeas:pmDaFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> </tr> </TBODY> </table> <div> </div> </td> </tr> <tr ><td > <div style="padding-bottom: 1.5em; width:90%;" > <span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:pmName" class="inputTextPct">The number and percent of waiver participants who express satisfaction with the quality of the services provided. The numerator is the number of clients reporting satisfaction and the denominator is the total number of participants surveyed</span> </div> </div> <table id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource" style="width: 90%" class="nstTableX" border="0" cellpadding="2" cellspacing="0" summary="dynamic table for Performance Measure Data Sources" ><tbody > <tr ><td ><label id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Analyzed collected data (including surveys, focus group, interviews, etc)</span><div id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct"></span></div></div></div><table id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:pmPnlGrdChkboxSet" class="nstTableX" border="1" cellpadding="3" cellspacing="0" style="vertical-align: top; margin-bottom: 1.5em;"> <tbody> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsRpSma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsSaPct" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaLtPct" class="outputText">Less than 100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsFdQu" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="inputTextarea" readonly="readonly">Fiscal Intermediary</textarea></span></div></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsFdCo" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsSaOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:dtDataSource:0:dssa6"></span></td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <div style="padding: 1em 0 1em 0;"> </div> <div> <span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:pmDAA" class="outputText" style="margin-top: 1.5em;">Data Aggregation and Analysis:</span> </div> <table id="pmPnlGrdChkboxSet" class="nstTableX" id="pmPnlGrdChkboxSet"cellpadding="3" cellspacing="0" border="1" style="vertical-align: top; width: 85%;"> <THEAD><tr align="left" valign="top"> <th id="rp" class="third"> <span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:txtPMfom2" class="outputTextNB em">(check each that applies):</span> </th> </tr></THEAD> <TBODY valign="top" align="left"> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:pmDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:pmDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:pmDaFdQu" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:pmDaRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:pmDaRpOthDsc" name="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:pmDaRpOthDsc" class="inputTextarea" readonly="readonly">Fiscal Intermediary</textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:pmDaFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:txtlbl_pmDaFdAn" class="outputText">Annually</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:pmDaFdCo" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:txtlblpmDaFdCo" class="outputText">Continuously and Ongoing</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup" > <input id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:pmDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:pmDaFdOtDsc" name="svapdxGQ_1:dtPMPrntHWD:1:svQmPerfMeas:pmDaFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> </tr> </TBODY> </table> <div> </div> </td> </tr> </tbody> </table> </div> </li> </ol> </li> <li style="padding-top: 1.5em;"> <!-- a.ii. --> <div class="paragraph"> <label id="svapdxGQ_1:lbl_qmHwDiscDesc" for="svapdxGQ_1:qmHwDiscDesc" class="outputLabel"> <span id="svapdxGQ_1:txt_lbl_qmHwDiscDesc" class="outputTextNB">If applicable, in the textbox below provide any necessary additional information on the strategies employed by the State to discover/identify problems/issues within the waiver program, including frequency and parties responsible.</span></label> </div> <div></div> <div class="chrCntDiv"> <label id="svapdxGQ_1:qmHwDiscDescChrCntLbl" for="svapdxGQ_1:qmHwDiscDescChrCnt" class="outputLabel"> <span id="svapdxGQ_1:qmHwDiscDescChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxGQ_1:qmHwDiscDescChrCnt" type="text" name="svapdxGQ_1:qmHwDiscDescChrCnt" class="chrCnt" size="6" /><span id="svapdxGQ_1:qmHwDiscDescChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxGQ_1:panel_qmHwDiscDesc"><textarea id="svapdxGQ_1:qmHwDiscDesc" name="svapdxGQ_1:qmHwDiscDesc" class="inputTextarea" onkeyup="Count(this);" readonly="readonly">n/a</textarea></span> </div> </li> </ol> </li> <li style="margin-top: 1em;"> <!-- b. --> <div class="paragraph"> <span class="outputText">Methods for Remediation/Fixing Individual Problems</span> </div> <ol class="romanLC" id="AQb" start="1"> <li> <!-- b.i. --> <div class="paragraph"> <label id="svapdxGQ_1:lbl_qmHwRemDesc" for="svapdxGQ_1:qmHwRemDesc" class="outputLabel"> <span id="svapdxGQ_1:txt_lbl_qmHwRemDesc" class="outputTextNB">Describe the State’s method for addressing individual problems as they are discovered. Include information regarding responsible parties and GENERAL methods for problem correction. In addition, provide information on the methods used by the State to document these items. </span></label> </div> <div></div> <div class="chrCntDiv"> <label id="svapdxGQ_1:qmHwRemDescChrCntLbl" for="svapdxGQ_1:qmHwRemDescChrCnt" class="outputLabel"> <span id="svapdxGQ_1:qmHwRemDescChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxGQ_1:qmHwRemDescChrCnt" type="text" name="svapdxGQ_1:qmHwRemDescChrCnt" class="chrCnt" size="6" /><span id="svapdxGQ_1:qmHwRemDescChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxGQ_1:panel_qmHwRemDesc"><textarea id="svapdxGQ_1:qmHwRemDesc" name="svapdxGQ_1:qmHwRemDesc" class="inputTextarea" onkeyup="Count(this);" readonly="readonly">If an employee is identified by the fiscal intermediary as having a criminal conviction, a report is sent to the case manager, the Program Manager and the employer is notified. Since the waiver is self directed the consumer is able to decide to hire the provider, by signing a release of liability form. If the Program Manager makes the decision that the crimes are too serious in nature to allow the hiring, they may refuse to allow the hiring pursuant to the State of Connecticut Regulation Sec. 17b-262-596 (c).</textarea></span> </div> </li> <li> <!-- b.ii. --> <div class="paragraph"> <span id="svapdxGQ_1:txt1">Remediation Data Aggregation</span> </div> <div> <span id="svapdxGQ_1:txt2">Remediation-related Data Aggregation and Analysis (including trend identification)</span> <table cellpadding="3" cellspacing="0" border="1" class="nstTableX" style="width: 80%;"> <thead align="left"> <tr> <th id="rp" style="width:44%;"> <span id="svapdxGQ_1:txtrp">Responsible Party</span><span id="svapdxGQ_1:txtrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" style="width:44%;"> <span id="svapdxGQ_1:txtfom">Frequency of data aggregation and analysis</span><span id="svapdxGQ_1:txtfom2" class="outputTextNB em">(check each that applies):</span> </th> </tr> </thead> <tbody align="left" valign="top"> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxGQ_1:qmHwDaRpSma" type="checkbox" name="svapdxGQ_1:qmHwDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:lbl_qmHwDaRpSma" for="svapdxGQ_1:qmHwDaRpSma" class="outputLabel"> <span id="svapdxGQ_1:txtlbl_qmHwDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:qmHwDaFdWk" type="checkbox" name="svapdxGQ_1:qmHwDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:lbl_qmHwDaFdWk" for="svapdxGQ_1:qmHwDaFdWk" class="outputLabel"> <span id="svapdxGQ_1:txtlbl_qmHwDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxGQ_1:qmHwDaRpOpa" type="checkbox" name="svapdxGQ_1:qmHwDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:lbl_qmHwDaRpOpa" for="svapdxGQ_1:qmHwDaRpOpa" class="outputLabel"> <span id="svapdxGQ_1:txtlbl_qmHwDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:qmHwDaFdMo" type="checkbox" name="svapdxGQ_1:qmHwDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:lbl_qmHwDaFdMo" for="svapdxGQ_1:qmHwDaFdMo" class="outputLabel"> <span id="svapdxGQ_1:txtlbl_qmHwDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxGQ_1:qmHwDaRpCma" type="checkbox" name="svapdxGQ_1:qmHwDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:lbl_qmHwDaRpCma" for="svapdxGQ_1:qmHwDaRpCma" class="outputLabel"> <span id="svapdxGQ_1:txtlbl_qmHwDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:qmHwDaFdQu" type="checkbox" name="svapdxGQ_1:qmHwDaFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:lbl_qmHwDaFdQu" for="svapdxGQ_1:qmHwDaFdQu" class="outputLabel"> <span id="svapdxGQ_1:txtlbl_qmHwDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxGQ_1:qmHwDaRpOth" type="checkbox" name="svapdxGQ_1:qmHwDaRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:lbl_qmHwDaRpOth" for="svapdxGQ_1:qmHwDaRpOth" class="outputLabel"> <span id="svapdxGQ_1:txtlbl_qmHwDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxGQ_1:lbl2_qmHwDaRpOthDsc" for="svapdxGQ_1:qmHwDaRpOthDsc" class="outputLabel"> <span id="svapdxGQ_1:txtlbl2_qmHwDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <p></p> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxGQ_1:panel_qmHwDaRpOthDsc"><textarea id="svapdxGQ_1:qmHwDaRpOthDsc" name="svapdxGQ_1:qmHwDaRpOthDsc" class="inputTextarea" readonly="readonly">Fiduciary contractor</textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:qmHwDaFdAn" type="checkbox" name="svapdxGQ_1:qmHwDaFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:lbl_qmHwDaFdAn" for="svapdxGQ_1:qmHwDaFdAn" class="outputLabel"> <span id="svapdxGQ_1:txtlbl_qmHwDaFdAn" class="outputText">Annually</span></label> </div> </td> </tr> <tr> <td headers="rp"> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:qmHwDaFdCo" type="checkbox" name="svapdxGQ_1:qmHwDaFdCo" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxGQ_1:lbl_qmHwDaFdCo" for="svapdxGQ_1:qmHwDaFdCo" class="outputLabel"> <span id="svapdxGQ_1:txtlblqmHwDaFdCo" class="outputText">Continuously and Ongoing</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:qmHwDaFdOt" type="checkbox" name="svapdxGQ_1:qmHwDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxGQ_1:lbl_qmHwDaFdOt" for="svapdxGQ_1:qmHwDaFdOt" class="outputLabel"> <span id="svapdxGQ_1:txtlblqmHwDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxGQ_1:lbl2_qmHwDaFdOtDsc" for="svapdxGQ_1:qmHwDaFdOtDsc" class="outputLabel"> <span id="svapdxGQ_1:txtlbl2qmHwDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <p></p> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxGQ_1:panel_qmHwDaFdOtDsc"><textarea id="svapdxGQ_1:qmHwDaFdOtDsc" name="svapdxGQ_1:qmHwDaFdOtDsc" class="inputTextarea" readonly="readonly"></textarea></span> </div> </div> </td> </tr> </tbody> </table> </div> </li> </ol> </li> <li style="margin-top: 1em;"> <!-- c. --> <div> <span class="outputText">Timelines</span> </div> <div> <label id="svapdxGQ_1:lbl_qmHwTimeLn" for="svapdxGQ_1:qmHwTimeLn" class="outputLabel"> <span id="svapdxGQ_1:txt_lbl_qmHwTimeLn" class="outputTextNB">When the State does not have all elements of the Quality Improvement Strategy in place, provide timelines to design methods for discovery and remediation related to the assurance of Health and Welfare that are currently non-operational.</span></label> <div> <div class="checkboxGroup"><label><input id="svapdxGQ_1:qmHwTimeLn:1" type="radio" name="svapdxGQ_1:qmHwTimeLn" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;No</label></div> <div class="checkboxGroup"><label><input id="svapdxGQ_1:qmHwTimeLn:0" type="radio" name="svapdxGQ_1:qmHwTimeLn" checked="checked" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;Yes</label></div> <div class="noShow"><label><input id="svapdxGQ_1:qmHwTimeLn:2" type="radio" name="svapdxGQ_1:qmHwTimeLn" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </div> </div> <div class="firstIndent"> <label id="svapdxGQ_1:lbl_qmHwTimeLnDsc" for="svapdxGQ_1:qmHwTimeLnDsc" class="outputLabel"> <span id="svapdxGQ_1:txt_lbl_qmHwTimeLnDsc" class="outputTextNB">Please provide a detailed strategy for assuring Health and Welfare, the specific timeline for implementing identified strategies, and the parties responsible for its operation.</span></label> <div></div> <div class="chrCntDiv"> <label id="svapdxGQ_1:qmHwTimeLnDscChrCntLbl" for="svapdxGQ_1:qmHwTimeLnDscChrCnt" class="outputLabel"> <span id="svapdxGQ_1:qmHwTimeLnDscChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxGQ_1:qmHwTimeLnDscChrCnt" type="text" name="svapdxGQ_1:qmHwTimeLnDscChrCnt" class="chrCnt" size="6" /><span id="svapdxGQ_1:qmHwTimeLnDscChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxGQ_1:panel_qualc"><textarea id="svapdxGQ_1:qmHwTimeLnDsc" name="svapdxGQ_1:qmHwTimeLnDsc" class="inputTextarea" readonly="readonly">In addition to during the initial assessment process the state will begin to require medical documentation during the redetermination process. This change will take effect October 1, 2009. Additionally, the critical incident reporting form will be operational October 1, 2009.</textarea></span> </div> </div> </li> </ol> <H2 id="pageTitle">Appendix H: Quality Improvement Strategy <SPAN id="pageNumber">(1 of 2)</SPAN></H2> <div class="outputTextNB paragraph"> <P class="pph"> Under §1915(c) of the Social Security Act and 42 CFR §441.302, the approval of an HCBS waiver requires that CMS determine that the State has made satisfactory assurances concerning the protection of participant health and welfare, financial accountability and other elements of waiver operations. Renewal of an existing waiver is contingent upon review by CMS and a finding by CMS that the assurances have been met. By completing the HCBS waiver application, the State specifies how it has designed the waiver&rsquo;s critical processes, structures and operational features in order to meet these assurances. </P> <ul> <li> Quality Improvement is a critical operational feature that an organization employs to continually determine whether it operates in accordance with the approved design of its program, meets statutory and regulatory assurances and requirements, achieves desired outcomes, and identifies opportunities for improvement. </li> </ul> <P class="pph"> CMS recognizes that a state&rsquo;s waiver Quality Improvement Strategy may vary depending on the nature of the waiver target population, the services offered, and the waiver&rsquo;s relationship to other public programs, and will extend beyond regulatory requirements. However, for the purpose of this application, the State is expected to have, at the minimum, systems in place to measure and improve its own performance in meeting six specific waiver assurances and requirements. </P> <P class="pph"> It may be more efficient and effective for a Quality Improvement Strategy to span multiple waivers and other long-term care services. CMS recognizes the value of this approach and will ask the state to identify other waiver programs and long-term care services that are addressed in the Quality Improvement Strategy. </P> </div> <div class="outputTextNB paragraph"> <H4 class="pph">Quality Improvement Strategy: Minimum Components</H4> <P class="pph"> The Quality Improvement Strategy that will be in effect during the period of the approved waiver is described throughout the waiver in the appendices corresponding to the statutory assurances and sub-assurances. Other documents cited must be available to CMS upon request through the Medicaid agency or the operating agency (if appropriate). </P> <p class="pph"> In the QIS discovery and remediation sections throughout the application (located in Appendices A, B, C, D, G, and I) , a state spells out: </p> <ul class="numeric outputTextNB"> <li> The evidence based discovery activities that will be conducted for each of the six major waiver assurances; </li> <li> The <em>remediation</em> activities followed to correct individual problems identified in the implementation of each of the assurances; </li> </ul> <p class="pph"> In Appendix H of the application, a State describes (1) the <em>system improvement</em> activities followed in response to aggregated, analyzed discovery and remediation information collected on each of the assurances; (2) the correspondent <em>roles/responsibilities</em> of those conducting assessing and prioritizing improving system corrections and improvements; and (3) the processes the state will follow to continuously <em>assess the effectiveness of the OIS</em> and revise it as necessary and appropriate. </p> <p class="pph"> If the State's Quality Improvement Strategy is not fully developed at the time the waiver application is submitted, the state may provide a work plan to fully develop its Quality Improvement Strategy, including the specific tasks the State plans to undertake during the period the waiver is in effect, the major milestones associated with these tasks, and the entity (or entities) responsible for the completion of these tasks. </p> <p class="pph"> When the Quality Improvement Strategy spans more than one waiver and/or other types of long-term care services under the Medicaid State plan, specify the control numbers for the other waiver programs and/or identify the other long-term services that are addressed in the Quality Improvement Strategy. In instances when the QIS spans more than one waiver, the State must be able to stratify information that is related to each approved waiver program. Unless the State has requested and received approval from CMS for the consolidation of multiple waivers for the purpose of reporting, then the State must stratify information that is related to each approved waiver program, i.e., employ a representative sample for each waiver. </p> </div> <H2 id="pageTitle">Appendix H: Quality Improvement Strategy <SPAN id="pageNumber">(2 of 2)</SPAN></H2> <H3 id="pageSubTitle">H-1: Systems Improvement</H3> <OL class="alphaLC" start="1"> <LI> <p class="outputText">System Improvements</p> <ol class="romanLC" start="1"> <li> <p class="outputTextNB"> <label id="svapdxH1_3:lbl_siProcSysImp" for="svapdxH1_3:siProcSysImp" class="outputLabel"> <span id="svapdxH1_3:lbltxt_siProcSysImp" class="outputTextNB">Describe the process(es) for trending, prioritizing, and implementing system improvements (i.e., design changes) prompted as a result of an analysis of discovery and remediation information.</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxH1_3:siProcSysImpChrCntLbl" for="svapdxH1_3:siProcSysImpChrCnt" class="outputLabel"> <span id="svapdxH1_3:siProcSysImpChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxH1_3:siProcSysImpChrCnt" type="text" name="svapdxH1_3:siProcSysImpChrCnt" class="chrCnt" size="6" /><span id="svapdxH1_3:siProcSysImpChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxH1_3:panel_siProcSysImp"><textarea id="svapdxH1_3:siProcSysImp" name="svapdxH1_3:siProcSysImp" class="inputTextarea" onkeyup="Count(this);" readonly="readonly">Assurance: Level of Care Level of Care (LOC) is determined at least annually and more frequently if needed. Care managers use a standardized “Level of Care Determination” instrument to assess need for services. This tool allows the Department to better evaluate whether there is reasonable indication that the consumer will require services in the future. After the care manager has determined a level of care, it is reviewed by department staff in the HCBS Unit for the final determination of functional eligibility for the waiver. All LOC determinations are required to be documented in the waiver consumer’s case record and a file is also maintained at Central Office. Care managers are required to do annual assessment twelve months from the date of the initial Central Office waiver approval. The documentation system has a tickler system to notify workers when the case is coming due for renewal. The process for the review is the same as the initial LOC determination. The care manager will conduct a home visit, assess the client needs as well as hear from consumers their needs; they will then complete the “Level of Care Determination.” This LOC is submitted to the HCBS Unit for final approval to insure compliance with all LOC waiver guidelines. When a consumer's service level is thought to be inappropriate during any part of the evaluation process, the individual is reassessed by the care manager with oversight by access agency supervisor. The new service level based on their ADL needs is approved or denied by DSS HCBS Unit staff. Any change in the consumer’s level of care generates a Notice of Action from the department indicating any plan changes. Clients are afforded the opportunity for a Fair Hearing in accordance with the Departmental Medicaid Policy. Services cannot be reduced until the hearing decision is issued, if a client requests a hearing within 10 days of the date of the NOA. Assurance: Service Plans To be eligible for waiver services consumers must require hands on assistance with at least two ADL’s. The care manager in consultation with the consumer and his/her representative develop a plan of care based on the consumer’s physical limitations governed by the number of ADL’s requiring physical assistance. Initial care plans are developed using a standardized form. This form requires development in the following areas: • Health • Life Planning • Behavioral Issues • Communication • Risk indicators • Functional Assessment • Community-Based Supports Cost of Care Plans are also developed and calculated. This plan includes all services funded under Medicaid and outside sources including PCA provided under the state plan, home health care, nursing services, PT/OT, PERS, and Home Delivered Meals. The Service Plan and the Cost of Care Plan are submitted to the department's HCBS Unit for review and approval. The PCA waiver is managed on a case-by-case basis, reflective of an approach to ensure that individual consumer’s presentations and needs are supported congruent with the eligible population standards. This service operates under ongoing oversight, checks and balances built in through contracts with the Access Agencies and oversight and monitoring by HCBS Unit staff. All client specific actions are documented in the consumer’s case record. All records, paper and electronic, are subject to periodic reviews by the HCBS Unit. The State’s requirement for documented client choice regarding institutional versus community-based services is evidenced through consumer attestation and signature as part of the waiver application process. Because this is a self directed model consumers have the responsibility to hire, manage, oversee and fire their own providers. Quality Improvement Strategies: The department will be utilizing the new Participant Experience Survey as a quality assurance tool to identify trends or areas in need of improvement. Assurance: Health and Welfare DSS administers and manages the PCA waiver using contracted Access Agency care managers who engage in client assessment and administrative management, fiduciary agent administered provider training, reporting and provider registry maintenance, and ongoing care plan review and management, the measures are in place to promote and protect the health and welfare of PCA waiver consumers. DSS also requires a clear emergency back-up plan be written for each consumer to better ensure services continuity, safety and uninterrupted care and support. Quality Improvement Strategies: DSS’s general agency quality assurance/improvement initiatives and activities apply to all programs it operates. Quality assurance activities with the Department include referrals to its Fraud and Recovery unit if a reported incident is of a fiscal nature. Additionally, the fiscal intermediary reports to care managers, consumer/employees and the Waiver Program Manager all potential providers who have been convicted of any of the crimes listed in the program regulations. The department determines whether to exercise its right to refuse to allow the hire for health and safety reasons. Assurance: Administrative Authority: DSS, as the state Medicaid Agency pursuant to Connecticut general Statutes (CGS) 17b-1, directly administers the PCA Waiver according to CGS Sec. 17b-605. DSS assures that all individuals receiving waiver services meet the categorically and medically needy eligibility and income/asset requirements. DSS informs individuals determined eligible to receive waiver services of their due process rights and gives them the choice of institutionalization or home and community based services. Quality Improvement Strategies: DSS contracts with the fiscal agent to conduct provider recruitment, training, engage in fiscal monitoring, claims processing and reporting. Quarterly reports, at a minimum are submitted to the Department to facilitate state oversight of the waiver program. It is the responsibility of the Waiver Program Manager to analyze the data and bring any pertinent information to the Management team and the Director if any systems problems need to be addressed. Assurance: Fiscal Accountability: DSS has contracted with the fiscal intermediary to maintain the payment records on services received and billed under the PCA waiver. The fiscal intermediary ensures that all billed services are within a consumer’s Plan of Care and submits appropriate claims to the Hewlett Packard Enterprise Services (HP). HP is a claims payment subcontractor of the Department. HP reviews the claim for Medicaid eligibility and other elements (i.e., hospitalization dates), before reimbursing the fiscal intermediary. The fiscal intermediary ensures that all services and corresponding claim payments are coded and properly documented. To ensure maximum reimbursement, the intermediary will report to DSS Central Office staff any difficulties with billing. Central Office staff will coordinate with access agency care managers and department eligibility staff staff and HP to resolve the payment issue. Additionally, the intermediary will generate, at the Departments request, a report identifying non-reimbursable charges with an explanation. Computerized service documentation system allows for the tracking of expenditures for each client, as well as the total waiver program. Care managers are available to respond to questions, and clarify for the consumer any issues related to the Cost of Care Plan or the Medicaid application process. This may also involve coordinating with DSS eligibility staff, to ensure that the consumer’s application is approved in a timely manner.</textarea></span> </div> </li> <li style="padding:1em 0 1em 0;"> <div> <span id="svapdxH1_3:sectH1aii">System Improvement Activities </span> <table cellpadding="3" cellspacing="0" border="1"> <thead align="left"> <tr> <th id="rp" style="width:50%;"> <span id="svapdxH1_3:txtrp">Responsible Party</span><span id="svapdxH1_3:txtrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" style="width:50%;"> <span id="svapdxH1_3:txtfom">Frequency of Monitoring and Analysis</span><span id="svapdxH1_3:txtfom2" class="outputTextNB em">(check each that applies):</span> </th> </tr> </thead> <tbody align="left"> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxH1_3:siRpSma" type="checkbox" name="svapdxH1_3:siRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxH1_3:lbl_siRpSma" for="svapdxH1_3:siRpSma" class="outputLabel"> <span id="svapdxH1_3:txtlbl_siRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxH1_3:siFomWk" type="checkbox" name="svapdxH1_3:siFomWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxH1_3:lbl_siFomWk" for="svapdxH1_3:siFomWk" class="outputLabel"> <span id="svapdxH1_3:txtlbl_siFomWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxH1_3:siRpOa" type="checkbox" name="svapdxH1_3:siRpOa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxH1_3:lbl_siRpOa" for="svapdxH1_3:siRpOa" class="outputLabel"> <span id="svapdxH1_3:txtlbl_siRpOa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxH1_3:siFomMo" type="checkbox" name="svapdxH1_3:siFomMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxH1_3:lbl_siFomMo" for="svapdxH1_3:siFomMo" class="outputLabel"> <span id="svapdxH1_3:txtlbl_siFomMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxH1_3:siRpCma" type="checkbox" name="svapdxH1_3:siRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxH1_3:lbl_siRpCma" for="svapdxH1_3:siRpCma" class="outputLabel"> <span id="svapdxH1_3:txtlbl_siRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxH1_3:siFomQu" type="checkbox" name="svapdxH1_3:siFomQu" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxH1_3:lbl_siFomQu" for="svapdxH1_3:siFomQu" class="outputLabel"> <span id="svapdxH1_3:txtlbl_siFomQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxH1_3:siRpQic" type="checkbox" name="svapdxH1_3:siRpQic" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxH1_3:lbl_siRpQic" for="svapdxH1_3:siRpQic" class="outputLabel"> <span id="svapdxH1_3:txtlbl_siRpQic" class="outputText">Quality Improvement Committee</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxH1_3:siFomAn" type="checkbox" name="svapdxH1_3:siFomAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxH1_3:lbl_siFomAn" for="svapdxH1_3:siFomAn" class="outputLabel"> <span id="svapdxH1_3:txtlbl_siFomAn" class="outputText">Annually</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxH1_3:siRpOther" type="checkbox" name="svapdxH1_3:siRpOther" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxH1_3:lbl_siRpOther" for="svapdxH1_3:siRpOther" class="outputLabel"> <span id="svapdxH1_3:txtlbl_siRpOther" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxH1_3:lbl2_siRpOtherSp" for="svapdxH1_3:siRpOtherSp" class="outputLabel"> <span id="svapdxH1_3:txtlbl2_siRpOtherSp" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxH1_3:panel_siRpOtherSp"><textarea id="svapdxH1_3:siRpOtherSp" name="svapdxH1_3:siRpOtherSp" class="inputTextarea2" readonly="readonly"></textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxH1_3:siFomOther" type="checkbox" name="svapdxH1_3:siFomOther" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxH1_3:lbl_siFomOther" for="svapdxH1_3:siFomOther" class="outputLabel"> <span id="svapdxH1_3:txtlblsiFomOther" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxH1_3:lbl2_siFomOtherSp" for="svapdxH1_3:siFomOtherSp" class="outputLabel"> <span id="svapdxH1_3:txtlbl2siFomOtherSp" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxH1_3:panel_siFomOtherSp"><textarea id="svapdxH1_3:siFomOtherSp" name="svapdxH1_3:siFomOtherSp" class="inputTextarea2" readonly="readonly">on going as needed</textarea></span> </div> </div> </td> </tr> </tbody> </table> </div> </li> </ol> </LI> <LI> <p class="outputText"> System Design Changes </p> <ol class="romanLC" start="1"> <li> <p class="outputTextNB"> <label id="svapdxH1_3:lbl_siProcSysDes" for="svapdxH1_3:siProcSysDes" class="outputLabel"> <span id="svapdxH1_3:lbltxt_siProcSysDes" class="outputTextNB">Describe the process for monitoring and analyzing the effectiveness of system design changes. Include a description of the various roles and responsibilities involved in the processes for monitoring &amp; assessing system design changes. If applicable, include the State's targeted standards for systems improvement.</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxH1_3:siProcSysDesChrCntLbl" for="svapdxH1_3:siProcSysDesChrCnt" class="outputLabel"> <span id="svapdxH1_3:siProcSysDesChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxH1_3:siProcSysDesChrCnt" type="text" name="svapdxH1_3:siProcSysDesChrCnt" class="chrCnt" size="6" /><span id="svapdxH1_3:siProcSysDesChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxH1_3:panel_siProcSysDes"><textarea id="svapdxH1_3:siProcSysDes" name="svapdxH1_3:siProcSysDes" class="inputTextarea" onkeyup="Count(this);" readonly="readonly">The Department contracts with the fiscal intermediary to provide the following activity and compliance reports: • administrative reports, • fiscal reports, • programmatic reports, • PCA registry updates • Reconciliation reports. The fiscal intermediary will also : • Provide an annual survey of Satisfaction/Quality/Evaluation with participants and communicate on an as needed basis with all participants regarding the services received from the contractor. • Use both telephone and print surveys to gather information. Surveys shall be conducted within sixty (60) days with all new Employers, conservators as appropriate, PCA’s, Department Social Workers and any other involved organizations or individuals. Thereafter surveys shall be solicited on a quarterly basis from a random sampling of 25% of active Employers. The surveys shall address the level of satisfaction with the procedures of intake, training, payment, financial services, on-going contact, availability of providers and service delivery by the PCA’s. • Address special concerns identified in the PCA Program survey as soon as practical • Summarize the survey information in quarterly annual reports to the Department. Additionally, the Department will conduct its own Satisfaction Survey, with the results compiled by the fiscal intermediary. The results of this survey are shared with DSS staff and the fiscal intermediary to resolve and address any identified problems or needed systems changes. The social work management team meets weekly to discuss the information provided by the fiscal intermediary and is responsible for the quality management of the PCA waiver program.</textarea></span> </div> </li> <li> <p class="outputTextNB"> <label id="svapdxH1_3:lbl_siProcSysEval" for="svapdxH1_3:siProcSysEval" class="outputLabel"> <span id="svapdxH1_3:lbltxt_siProcSysEval" class="outputTextNB">Describe the process to periodically evaluate, as appropriate, the Quality Improvement Strategy.</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxH1_3:siProcSysEvalChrCntLbl" for="svapdxH1_3:siProcSysEvalChrCnt" class="outputLabel"> <span id="svapdxH1_3:siProcSysEvalChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxH1_3:siProcSysEvalChrCnt" type="text" name="svapdxH1_3:siProcSysEvalChrCnt" class="chrCnt" size="6" /><span id="svapdxH1_3:siProcSysEvalChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxH1_3:panel_siProcSysEval"><textarea id="svapdxH1_3:siProcSysEval" name="svapdxH1_3:siProcSysEval" class="inputTextarea" onkeyup="Count(this);" readonly="readonly">The Waiver Manager will as needed evaluate information presented by the Fiscal Intermediary.</textarea></span> </div> </li> </ol> </LI> </OL> <H2 id="pageTitle">Appendix I: Financial Accountability</H2> <H3 id="pageSubTitle">I-1: Financial Integrity and Accountability</H3> <div class="firstIndent"> <p class="outputTextNB"> <strong>Financial Integrity. </strong> <label id="svapdxI1_1:lblfnaOvrvw" for="svapdxI1_1:fnaOvrvw" class="outputLabel"> <span id="svapdxI1_1:lbltxtfnaOvrvw" class="outputTextNB">Describe the methods that are employed to ensure the integrity of payments that have been made for waiver services, including: (a) requirements concerning the independent audit of provider agencies; (b) the financial audit program that the state conducts to ensure the integrity of provider billings for Medicaid payment of waiver services, including the methods, scope and frequency of audits; and, (c) the agency (or agencies) responsible for conducting the financial audit program. State laws, regulations, and policies referenced in the description are available to CMS upon request through the Medicaid agency or the operating agency (if applicable).</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxI1_1:fnaOvrvwChrCntLbl" for="svapdxI1_1:fnaOvrvwChrCnt" class="outputLabel"> <span id="svapdxI1_1:fnaOvrvwChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxI1_1:fnaOvrvwChrCnt" type="text" name="svapdxI1_1:fnaOvrvwChrCnt" class="chrCnt" size="6" /><span id="svapdxI1_1:fnaOvrvwChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxI1_1:panel_fnaOvrvw"><textarea id="svapdxI1_1:fnaOvrvw" name="svapdxI1_1:fnaOvrvw" class="inputTextareaLong" onkeyup="Count(this);" readonly="readonly">The Department of Social Services has contracted with a fiscal intermediary to maintain the payment records for services received and billed under the PCA Waiver. The fiscal intermediary, Allied Community Resources, INC (ACR) ensures that all billed services emanate from an approved consumer plan of care and submits appropriate claims to Hewlett Packard Enterprise Services (HP), who is a claims payment subcontractor of the Department. HP reviews the claim for Medicaid eligibility and other elements.(i.e., spend-down requirements) before reimbursing the fiscal agent. ACR ensures that all services and corresponding claim payments are coded and properly documented. The DSS Office of Quality Assurance (QA) conducts financial audits of Medicaid providers and issues exceptions when appropriate for issues of non-compliance with the State'’s policy requirements. The Office of Quality Assurance activities extend to all DSS programs, and office staff persons are located at the central and regional DSS offices. Functions are grouped into three major areas of focus-audits, quality control, and fraud and recoveries. All waiver providers are subject to audits performed by the QA. Overall audit demands and audit resources available to DSS QA impact the frequency of audit and waiver providers. These audits include ad hoc reviews when ACR or DSS Social Work Services staff, alert QA to potential issues. Audits of payments to providers are most commonly performed on a universe of claim payments within a two year period. A random sample of 100 claims is chosen. The auditor reviews supporting documentation maintained by the provider and claim information maintained by the department. The purpose of the review is to determine if services and associated payments were made in accordance with applicable state regulations. Errors identified in the sample are extrapolated to the universe of paid claims to arrive at a financial audit adjustment.</textarea></span> </div> </div> <H2 id="pageTitle">Appendix I: Financial Accountability</H2> <H3 id="pageSubTitle">Quality Improvement: Financial Accountability</H3> <div class="paragraph"> <span class="outputTextNB em"> As a distinct component of the State’s quality improvement strategy, provide information in the following fields to detail the State’s methods for discovery and remediation. </span> </div> <ol class="alphaLC" id="AQa" start="1" > <li style="margin-top: 1em;"> <div class="paragraph"> <span class="outputText">Methods for Discovery: Financial Accountability Assurance:</span> </div> <div class="paragraph em"> <span class="outputText">The State must demonstrate that it has designed and implemented an adequate system for ensuring financial accountability of the waiver program.</span> <span class="outputTextNB"> (For waiver actions submitted before June 1, 2014, this assurance read "State financial oversight exists to assure that claims are coded and paid for in accordance with the reimbursement methodology specified in the approved waiver.")</span> </div> <ol class="romanLC" id="AQai" start="1"> <li> <!-- a.i. --> <div>Sub-Assurances:</div> <ol class="alphaLC" start="1"> <li style="padding-bottom: 1em;"> <!-- a.i.a --> <div> <p> <span id="svapdxIQ_1:aiaSA" class="outputText em">Sub-assurance: The State provides evidence that claims are coded and paid for in accordance with the reimbursement methodology specified in the approved waiver and only for services rendered.</span> <span class="outputTextNB em" > (Performance measures in this sub-assurance include all Appendix I performance measures for waiver actions submitted before June 1, 2014.)</span> </p> <p class="pph"> <span class="outputText">Performance Measures</span> </p> <p class="pph"> <span id="svapdxIQ_1:aiaPMInfo1" class="outputTextNB em">For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.</span> </p> <p class="pph"> <span id="svapdxIQ_1:aiaPMInstr1" class="outputTextNB em ul">For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.</span> </p> </div> <div class=""> <table id="svapdxIQ_1:dtPMPrntFA" class="nstTableX" summary="Expanded dynamic table for services" ><tbody > <tr ><td > <div style="padding-bottom: 1.5em; width:90%;" > <span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:pmName" class="inputTextPct">Number and Percent of quarterly reports recieved from the Fiscal intermediary will demonstrate timely payments of all claims. Numerator = quarterly reports recieved from the fiscal intermediary as specified in their contract. Denominator= total number of reports recieved.</span> </div> </div> <table id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource" style="width: 90%" class="nstTableX" border="0" cellpadding="2" cellspacing="0" summary="dynamic table for Performance Measure Data Sources" ><tbody > <tr ><td ><label id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Reports to State Medicaid Agency on delegated</span><div id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct"></span></div></div></div><table id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:pmPnlGrdChkboxSet" class="nstTableX" border="1" cellpadding="3" cellspacing="0" style="vertical-align: top; margin-bottom: 1.5em;"> <tbody> <tr> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsRpSma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsSaPct" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaLtPct" class="outputText">Less than 100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsFdQu" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="inputTextarea" readonly="readonly">fiscal intermediary</textarea></span></div></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsFdCo" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsSaOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsFdOt" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="inputTextarea" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:dtDataSource:0:dssa6"></span></td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <div style="padding: 1em 0 1em 0;"> </div> <div> <span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:pmDAA" class="outputText" style="margin-top: 1.5em;">Data Aggregation and Analysis:</span> </div> <table id="pmPnlGrdChkboxSet" class="nstTableX" id="pmPnlGrdChkboxSet"cellpadding="3" cellspacing="0" border="1" style="vertical-align: top; width: 85%;"> <THEAD><tr align="left" valign="top"> <th id="rp" class="third"> <span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:txtPMfom2" class="outputTextNB em">(check each that applies):</span> </th> </tr></THEAD> <TBODY valign="top" align="left"> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:pmDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:pmDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:pmDaFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:pmDaRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:pmDaRpOthDsc" name="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:pmDaRpOthDsc" class="inputTextarea" readonly="readonly">fiscal intermediary</textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:pmDaFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:txtlbl_pmDaFdAn" class="outputText">Annually</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:pmDaFdCo" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:txtlblpmDaFdCo" class="outputText">Continuously and Ongoing</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup" > <input id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:pmDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:pmDaFdOtDsc" name="svapdxIQ_1:dtPMPrntFA:0:svQmPerfMeas:pmDaFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> </tr> </TBODY> </table> <div> </div> </td> </tr> </tbody> </table> </div> </li> <li style="padding-bottom: 1em;"> <!-- a.i.b --> <div> <p> <span id="svapdxIQ_1:aibSA" class="outputText em">Sub-assurance: The state provides evidence that rates remain consistent with the approved rate methodology throughout the five year waiver cycle.</span> </p> <p class="pph"> <span class="outputText">Performance Measures</span> </p> <p class="pph"> <span id="svapdxIQ_1:aibPMInfo1" class="outputTextNB em">For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.</span> </p> <p class="pph"> <span id="svapdxIQ_1:aibPMInstr1" class="outputTextNB em ul">For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.</span> </p> </div> <div class=""> <table id="svapdxIQ_1:dtPMPrntFAB" class="nstTableX" summary="Expanded dynamic table for services" ><tbody > <tr ><td > <div style="padding-bottom: 1.5em; width:90%;" > <span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:pmName" class="inputTextPct">The number and percent of rates that remain consistent with the methodology through the entire waiver cycle. Numerator is the number of rates that stay consistent in methodology and the denominator is the total number of rates.</span> </div> </div> <table id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource" style="width: 90%" class="nstTableX" border="0" cellpadding="2" cellspacing="0" summary="dynamic table for Performance Measure Data Sources" ><tbody > <tr ><td ><label id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Other</span><div id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct">Data warehouse reports</span></div></div></div><table id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:pmPnlGrdChkboxSet" class="nstTableX" border="1" cellpadding="3" cellspacing="0" style="vertical-align: top; margin-bottom: 1.5em;"> <tbody> <tr> <td class="third"><span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsSaPct" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaLtPct" class="outputText">Less than 100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsFdAn" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsFdCo" checked="checked" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsSaOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:dtDataSource:0:dssa6"></span></td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <div style="padding: 1em 0 1em 0;"> </div> <div> <span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:pmDAA" class="outputText" style="margin-top: 1.5em;">Data Aggregation and Analysis:</span> </div> <table id="pmPnlGrdChkboxSet" class="nstTableX" id="pmPnlGrdChkboxSet"cellpadding="3" cellspacing="0" border="1" style="vertical-align: top; width: 85%;"> <THEAD><tr align="left" valign="top"> <th id="rp" class="third"> <span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:txtPMfom2" class="outputTextNB em">(check each that applies):</span> </th> </tr></THEAD> <TBODY valign="top" align="left"> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:pmDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:pmDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:pmDaFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:pmDaRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:pmDaRpOthDsc" name="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:pmDaRpOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:pmDaFdAn" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:txtlbl_pmDaFdAn" class="outputText">Annually</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:pmDaFdCo" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:txtlblpmDaFdCo" class="outputText">Continuously and Ongoing</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup" > <input id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:pmDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:pmDaFdOtDsc" name="svapdxIQ_1:dtPMPrntFAB:0:svQmPerfMeas:pmDaFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> </tr> </TBODY> </table> <div> </div> </td> </tr> <tr ><td > <div style="padding-bottom: 1.5em; width:90%;" > <span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:pmName" class="inputTextPct">The number and percent of claims for services that the fiscal intermediary are coded and properly documented. The numerator is the number of claims coded correctly and the denominator is the total number of claims</span> </div> </div> <table id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource" style="width: 90%" class="nstTableX" border="0" cellpadding="2" cellspacing="0" summary="dynamic table for Performance Measure Data Sources" ><tbody > <tr ><td ><label id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Other</span><div id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct">Review of submitted claims/time sheets</span></div></div></div><table id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:pmPnlGrdChkboxSet" class="nstTableX" border="1" cellpadding="3" cellspacing="0" style="vertical-align: top; margin-bottom: 1.5em;"> <tbody> <tr> <td class="third"><span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsRpSma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsFdWk" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsSaPct" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaLtPct" class="outputText">Less than 100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="inputTextarea" readonly="readonly">Fiscal intermediary</textarea></span></div></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsFdCo" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsSaOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:dtDataSource:0:dssa6"></span></td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <div style="padding: 1em 0 1em 0;"> </div> <div> <span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:pmDAA" class="outputText" style="margin-top: 1.5em;">Data Aggregation and Analysis:</span> </div> <table id="pmPnlGrdChkboxSet" class="nstTableX" id="pmPnlGrdChkboxSet"cellpadding="3" cellspacing="0" border="1" style="vertical-align: top; width: 85%;"> <THEAD><tr align="left" valign="top"> <th id="rp" class="third"> <span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:txtPMfom2" class="outputTextNB em">(check each that applies):</span> </th> </tr></THEAD> <TBODY valign="top" align="left"> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:pmDaRpSma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:pmDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:pmDaFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:pmDaRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:pmDaRpOthDsc" name="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:pmDaRpOthDsc" class="inputTextarea" readonly="readonly">Fiscal intermediary</textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:pmDaFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:txtlbl_pmDaFdAn" class="outputText">Annually</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:pmDaFdCo" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:txtlblpmDaFdCo" class="outputText">Continuously and Ongoing</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup" > <input id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:pmDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:pmDaFdOtDsc" name="svapdxIQ_1:dtPMPrntFAB:1:svQmPerfMeas:pmDaFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> </tr> </TBODY> </table> <div> </div> </td> </tr> </tbody> </table> </div> </li> </ol> </li> <li style="padding-top: 1.5em;"> <!-- a.ii. --> <div class="paragraph"> <label id="svapdxIQ_1:lbl_qmFaDiscDesc" for="svapdxIQ_1:qmFaDiscDesc" class="outputLabel"> <span id="svapdxIQ_1:txt_lbl_qmFaDiscDesc" class="outputTextNB">If applicable, in the textbox below provide any necessary additional information on the strategies employed by the State to discover/identify problems/issues within the waiver program, including frequency and parties responsible.</span></label> </div> <div></div> <div class="chrCntDiv"> <label id="svapdxIQ_1:qmFaDiscDescChrCntLbl" for="svapdxIQ_1:qmFaDiscDescChrCnt" class="outputLabel"> <span id="svapdxIQ_1:qmFaDiscDescChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxIQ_1:qmFaDiscDescChrCnt" type="text" name="svapdxIQ_1:qmFaDiscDescChrCnt" class="chrCnt" size="6" /><span id="svapdxIQ_1:qmFaDiscDescChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxIQ_1:panel_qmFaDiscDesc"><textarea id="svapdxIQ_1:qmFaDiscDesc" name="svapdxIQ_1:qmFaDiscDesc" class="inputTextarea" onkeyup="Count(this);" readonly="readonly">DSS has contracted with a fiscal intermediary to maintain the payment records on services received and billed under the PCA waiver. The fiscal intermediary ensures that all billed services are within a consumer’s Plan of Care and submits appropriate claims to HP. HP is a claims payment subcontractor of the Department. HP reviews the claim for Medicaid eligibility and other elements (i.e., hospitalization dates), before reimbursing the fiscal agent. The fiscal intermediary ensures that all services and corresponding claim payments are coded and properly documented. To ensure maximum reimbursement, the fiscal intermediary will report to DSS Central Office staff any difficulties with billing. Central Office staff will coordinate with eligibility staff and HP to resolve the payment issue. Additionally, the fiscal intermediary will generate, at the Departments request, a report identifying non-reimbursable charges with an explanation. Finally, computerized service documentation system allows for the tracking of expenditures for each client (approved cost of the plan) as well as the total waiver program. Regional Level Social Workers are available to respond to questions, and clarify for the consumer any issues related to the Cost of Care Plan or the Medicaid application process. This may also involve coordinating with DSS eligibility staff, to ensure that the consumer’s application is approved in a timely manner.</textarea></span> </div> </li> </ol> </li> <li style="margin-top: 1em;"> <!-- b. --> <div class="paragraph"> <span class="outputText">Methods for Remediation/Fixing Individual Problems</span> </div> <ol class="romanLC" id="AQb" start="1"> <li> <!-- b.i. --> <div class="paragraph"> <label id="svapdxIQ_1:lbl_qmFaRemDesc" for="svapdxIQ_1:qmFaRemDesc" class="outputLabel"> <span id="svapdxIQ_1:txt_lbl_qmFaRemDesc" class="outputTextNB">Describe the State’s method for addressing individual problems as they are discovered. Include information regarding responsible parties and GENERAL methods for problem correction. In addition, provide information on the methods used by the State to document these items. </span></label> </div> <div></div> <div class="chrCntDiv"> <label id="svapdxIQ_1:qmFaRemDescChrCntLbl" for="svapdxIQ_1:qmFaRemDescChrCnt" class="outputLabel"> <span id="svapdxIQ_1:qmFaRemDescChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxIQ_1:qmFaRemDescChrCnt" type="text" name="svapdxIQ_1:qmFaRemDescChrCnt" class="chrCnt" size="6" /><span id="svapdxIQ_1:qmFaRemDescChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxIQ_1:panel_qmFaRemDesc"><textarea id="svapdxIQ_1:qmFaRemDesc" name="svapdxIQ_1:qmFaRemDesc" class="inputTextarea" onkeyup="Count(this);" readonly="readonly">DSS staff assigned to the ACR contract is responsible to ensure that communication occurs on a daily basis with the fiscal intermediary. He/she is the liaison between the fiscal intermediary and eligibility and will communicate any issues that need to be resolved and follow up to insure they are resolved. If the issue is not something that can be resolved, he will bring it to the attention on the Waiver Program Manager who will intervene.</textarea></span> </div> </li> <li> <!-- b.ii. --> <div class="paragraph"> <span id="svapdxIQ_1:txt1">Remediation Data Aggregation</span> </div> <div> <span id="svapdxIQ_1:txt2">Remediation-related Data Aggregation and Analysis (including trend identification)</span> <table cellpadding="3" cellspacing="0" border="1" class="nstTableX" style="width:88%;"> <thead align="left"> <tr> <th id="rp" style="width:44%;"> <span id="svapdxIQ_1:txtrp">Responsible Party</span><span id="svapdxIQ_1:txtrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" style="width:44%;"> <span id="svapdxIQ_1:txtfom">Frequency of data aggregation and analysis</span><span id="svapdxIQ_1:txtfom2" class="outputTextNB em">(check each that applies):</span> </th> </tr> </thead> <tbody align="left" valign="top"> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxIQ_1:qmFaDaRpSma" type="checkbox" name="svapdxIQ_1:qmFaDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:lbl_qmFaDaRpSma" for="svapdxIQ_1:qmFaDaRpSma" class="outputLabel"> <span id="svapdxIQ_1:txtlbl_qmFaDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxIQ_1:qmFaDaFdWk" type="checkbox" name="svapdxIQ_1:qmFaDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:lbl_qmFaDaFdWk" for="svapdxIQ_1:qmFaDaFdWk" class="outputLabel"> <span id="svapdxIQ_1:txtlbl_qmFaDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxIQ_1:qmFaDaRpOpa" type="checkbox" name="svapdxIQ_1:qmFaDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:lbl_qmFaDaRpOpa" for="svapdxIQ_1:qmFaDaRpOpa" class="outputLabel"> <span id="svapdxIQ_1:txtlbl_qmFaDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxIQ_1:qmFaDaFdMo" type="checkbox" name="svapdxIQ_1:qmFaDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:lbl_qmFaDaFdMo" for="svapdxIQ_1:qmFaDaFdMo" class="outputLabel"> <span id="svapdxIQ_1:txtlbl_qmFaDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxIQ_1:qmFaDaRpCma" type="checkbox" name="svapdxIQ_1:qmFaDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:lbl_qmFaDaRpCma" for="svapdxIQ_1:qmFaDaRpCma" class="outputLabel"> <span id="svapdxIQ_1:txtlbl_qmFaDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxIQ_1:qmFaDaFdQu" type="checkbox" name="svapdxIQ_1:qmFaDaFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:lbl_qmFaDaFdQu" for="svapdxIQ_1:qmFaDaFdQu" class="outputLabel"> <span id="svapdxIQ_1:txtlbl_qmFaDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxIQ_1:qmFaDaRpOth" type="checkbox" name="svapdxIQ_1:qmFaDaRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:lbl_qmFaDaRpOth" for="svapdxIQ_1:qmFaDaRpOth" class="outputLabel"> <span id="svapdxIQ_1:txtlbl_qmFaDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxIQ_1:lbl2_qmFaDaRpOthDsc" for="svapdxIQ_1:qmFaDaRpOthDsc" class="outputLabel"> <span id="svapdxIQ_1:txtlbl2_qmFaDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxIQ_1:panel_qmFaDaRpOthDsc"><textarea id="svapdxIQ_1:qmFaDaRpOthDsc" name="svapdxIQ_1:qmFaDaRpOthDsc" class="inputTextarea" readonly="readonly"></textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxIQ_1:qmFaDaFdAn" type="checkbox" name="svapdxIQ_1:qmFaDaFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:lbl_qmFaDaFdAn" for="svapdxIQ_1:qmFaDaFdAn" class="outputLabel"> <span id="svapdxIQ_1:txtlbl_qmFaDaFdAn" class="outputText">Annually</span></label> </div> </td> </tr> <tr> <td headers="rp"> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxIQ_1:qmFaDaFdCo" type="checkbox" name="svapdxIQ_1:qmFaDaFdCo" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxIQ_1:lbl_qmFaDaFdCo" for="svapdxIQ_1:qmFaDaFdCo" class="outputLabel"> <span id="svapdxIQ_1:txtlblqmFaDaFdCo" class="outputText">Continuously and Ongoing</span></label> </div> </td> </tr> <tr> <td headers="rp"></td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxIQ_1:qmFaDaFdOt" type="checkbox" name="svapdxIQ_1:qmFaDaFdOt" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxIQ_1:lbl_qmFaDaFdOt" for="svapdxIQ_1:qmFaDaFdOt" class="outputLabel"> <span id="svapdxIQ_1:txtlblqmFaDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxIQ_1:lbl2_qmFaDaFdOtDsc" for="svapdxIQ_1:qmFaDaFdOtDsc" class="outputLabel"> <span id="svapdxIQ_1:txtlbl2qmFaDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxIQ_1:panel_qmFaDaFdOtDsc"><textarea id="svapdxIQ_1:qmFaDaFdOtDsc" name="svapdxIQ_1:qmFaDaFdOtDsc" class="inputTextarea" readonly="readonly">as requested</textarea></span> </div> </div> </td> </tr> </tbody> </table> </div> </li> </ol> </li> <li style="margin-top: 1em;"> <!-- c. --> <div> <span class="outputText">Timelines</span> </div> <div> <label id="svapdxIQ_1:lbl_qmFaTimeLn" for="svapdxIQ_1:qmFaTimeLn" class="outputLabel"> <span id="svapdxIQ_1:txt_lbl_qmFaTimeLn" class="outputTextNB">When the State does not have all elements of the Quality Improvement Strategy in place, provide timelines to design methods for discovery and remediation related to the assurance of Financial Accountability that are currently non-operational.</span></label> <div> <div class="checkboxGroup"><label><input id="svapdxIQ_1:qmFaTimeLn:1" type="radio" name="svapdxIQ_1:qmFaTimeLn" checked="checked" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;No</label></div> <div class="checkboxGroup"><label><input id="svapdxIQ_1:qmFaTimeLn:0" type="radio" name="svapdxIQ_1:qmFaTimeLn" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;Yes</label></div> <div class="noShow"><label><input id="svapdxIQ_1:qmFaTimeLn:2" type="radio" name="svapdxIQ_1:qmFaTimeLn" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </div> </div> <div class="firstIndent"> <label id="svapdxIQ_1:lbl_qmFaTimeLnDsc" for="svapdxIQ_1:qmFaTimeLnDsc" class="outputLabel"> <span id="svapdxIQ_1:txt_lbl_qmFaTimeLnDsc" class="outputTextNB">Please provide a detailed strategy for assuring Financial Accountability, the specific timeline for implementing identified strategies, and the parties responsible for its operation.</span></label> <div></div> <div class="chrCntDiv"> <label id="svapdxIQ_1:qmFaTimeLnDscChrCntLbl" for="svapdxIQ_1:qmFaTimeLnDscChrCnt" class="outputLabel"> <span id="svapdxIQ_1:qmFaTimeLnDscChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxIQ_1:qmFaTimeLnDscChrCnt" type="text" name="svapdxIQ_1:qmFaTimeLnDscChrCnt" class="chrCnt" size="6" /><span id="svapdxIQ_1:qmFaTimeLnDscChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxIQ_1:panel_qualc"><textarea id="svapdxIQ_1:qmFaTimeLnDsc" name="svapdxIQ_1:qmFaTimeLnDsc" class="inputTextarea" readonly="readonly"></textarea></span> </div> </div> </li> </ol> <H2 id="pageTitle">Appendix I: Financial Accountability</H2> <H3 id="pageSubTitle">I-2: Rates, Billing and Claims <SPAN id="pageNumber">(1 of 3)</SPAN></H3> <ol class="alphaLC" start="1"> <li> <p class="outputTextNB"> <strong>Rate Determination Methods. </strong> <label id="svapdxI2_1:lblfnaRatDetMth" for="svapdxI2_1:fnaRatDetMth" class="outputLabel"> <span id="svapdxI2_1:lbltxtfnaRatDetMth" class="outputTextNB">In two pages or less, describe the methods that are employed to establish provider payment rates for waiver services and the entity or entities that are responsible for rate determination. Indicate any opportunity for public comment in the process. If different methods are employed for various types of services, the description may group services for which the same method is employed. State laws, regulations, and policies referenced in the description are available upon request to CMS through the Medicaid agency or the operating agency (if applicable).</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxI2_1:fnaRatDetMthChrCntLbl" for="svapdxI2_1:fnaRatDetMthChrCnt" class="outputLabel"> <span id="svapdxI2_1:fnaRatDetMthChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxI2_1:fnaRatDetMthChrCnt" type="text" name="svapdxI2_1:fnaRatDetMthChrCnt" class="chrCnt" size="6" /><span id="svapdxI2_1:fnaRatDetMthChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxI2_1:panel_fnaRatDetMth"><textarea id="svapdxI2_1:fnaRatDetMth" name="svapdxI2_1:fnaRatDetMth" class="inputTextarea" onkeyup="Count(this);" readonly="readonly">Pursuant to Connecticut Department of Social Services Provider manual all schedules of payment for coverable Medical Assistance Program goods and services shall be established by the Commissioner and paid by the department in accordance with all applicable federal and state statutes and regulations. Waiver services rates are based on a trended 2.5% increase on rates established in the initial PCA waiver. Input on the waiver, including rates were afforded to all parties who commented on the PCA waiver to support the application. This includes consumers, family, and providers. Clients are notified of any changes to payment rates by the care manager and/or the fiscal intermediary. For the addition of Adult Family Living/Foster Care, the Department published notice and accepted comments on the new service and rates. The final approval was given by the Legislative Committees of cognizance after a public comment period. The efficient and economic rates for the various levels of Adult Family Living/Foster Care were developed by the Department's rate setting unit. The rates were built on a rate established based on a cost comparable to two hours per day or Homemaker service and one hour of companion, since this comports with the expectation of the preparation of meals and housekeeping service. There were add-ons at each level of the service based on the individual participants assessed cognitive, functional and behavioral needs. At each level the rate increases because the participant's needs increase requiring additional care. The add ons were based on the comparable number of hours and costs for the PCA service.The initial rate for Adult Family Living was a historic cost based rate. Add-ons were the equivalent of the base rate plus a cost allocation for the average number of hours of personal care that would be needed. For example Level 2 would be the base rate plus the approximate cost of 1.5 hours per day of personal care. The Independent Support Broker rate is based on a review of direct and indirect costs and is paid off the department's fee schedule. Case management is provided as an new service under this waiver. There are four procedure codes that are billable. They are initial assessment, reassessment, status review and ongoing care management. The rates were based on direct and indirect costs and billed off the department's fee schedule. The rate methodology for care management (per diem) was cost-based, determined by the budgets submitted by each Access Agency in response to the RFP. The rates for assessments, status reviews and annual reassessments were also based on costs and budgets in the RFP. Based on requirements of each service, status reviews are billed at one third the cost of the assessment and the annual reassessment is seventy five percent of the cost of a full assessment. The base rate for CM was Tier B and was determined as a result of the RFP and contract negotiations with the providers. The rates for Tiers A and C were determined based on the time requirements for client contacts and visits either subtracting from or adding to the Tier B rate. All three tiers of the care management service are billed as a per diem service. The assessment, reassessment and status reviews have specific procedure codes specific rates for the unit of service.</textarea></span> </div> </li> <li> <p class="outputTextNB"> <strong>Flow of Billings.</strong> <label id="svapdxI2_1:lblfnaFlwBllng" for="svapdxI2_1:fnaFlwBllng" class="outputLabel"> <span id="svapdxI2_1:lbltxtfnaFlwBllng" class="outputTextNB">Describe the flow of billings for waiver services, specifying whether provider billings flow directly from providers to the State's claims payment system or whether billings are routed through other intermediary entities. If billings flow through other intermediary entities, specify the entities:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxI2_1:fnaFlwBllngChrCntLbl" for="svapdxI2_1:fnaFlwBllngChrCnt" class="outputLabel"> <span id="svapdxI2_1:fnaFlwBllngChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxI2_1:fnaFlwBllngChrCnt" type="text" name="svapdxI2_1:fnaFlwBllngChrCnt" class="chrCnt" size="6" /><span id="svapdxI2_1:fnaFlwBllngChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxI2_1:panel_fnaFlwBllng"><textarea id="svapdxI2_1:fnaFlwBllng" name="svapdxI2_1:fnaFlwBllng" class="inputTextarea" onkeyup="Count(this);" readonly="readonly">Payments are made by the Medicaid agency directly to the providers of waiver and State plan services. There are provider agreements between DSS and the provider of services under the waiver. Payments for all waiver and other State plan services are to be made through an approved Connecticut’s Medicaid Management Information System (MMIS). DSS pays providers through the same fiscal agent used in the rest of the Medicaid program. DSS also uses a limited fiscal agent who functions only to validate payment of waiver claims, as supported by the participant's services plan. For Adult Family Living/Foster Care, the contracted agency will bill the Fiduciary Agency based on the rate for the level of service authorized in the plan of care. The provider agency will pay the direct care provider for the provision of services.</textarea></span> </div> </li> </ol> <H2 id="pageTitle">Appendix I: Financial Accountability</H2> <H3 id="pageSubTitle">I-2: Rates, Billing and Claims <SPAN id="pageNumber">(2 of 3)</SPAN></H3> <ol class="alphaLC" start="3"> <li> <p class="outputTextNB"><strong>Certifying Public Expenditures</strong> <em>(select one)</em>: </p> <table id="svapdxI2_2:fnaCPE" class="selectOneRadio"> <tr> <td> <input type="radio" checked="checked" name="svapdxI2_2:fnaCPE" id="svapdxI2_2:fnaCPE:0" value="0" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxI2_2:fnaCPE:0"> No. State or local government agencies do not certify expenditures for waiver services.</label></td> </tr> <tr> <td> <input type="radio" name="svapdxI2_2:fnaCPE" id="svapdxI2_2:fnaCPE:1" value="1" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxI2_2:fnaCPE:1"> Yes. State or local government agencies directly expend funds for part or all of the cost of waiver services and certify their State government expenditures (CPE) in lieu of billing that amount to Medicaid.</label></td> </tr> </table> <!-- rendered="#{(varFactory.fnaCPE == 1)?true:false}"> --> <div class="firstIndent"> <p class="outputText"><em>Select at least one</em>:</p> <div class="checkboxGroup"> <input id="svapdxI2_2:fnaCPESt" type="checkbox" name="svapdxI2_2:fnaCPESt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxI2_2:lbl_fnaCPESt" for="svapdxI2_2:fnaCPESt" class="outputLabel"> <span id="svapdxI2_2:lbltxt_fnaCPESt" class="outputText">Certified Public Expenditures (CPE) of State Public Agencies.</span></label> </div> <div class="firstIndent"> <p class="outptuTextNB"> <label id="svapdxI2_2:lblfnaCPEStDscr" for="svapdxI2_2:fnaCPEStDscr" class="outputLabel"> <span id="svapdxI2_2:lbltxtfnaCPEStDscr1" class="outputTextNB">Specify: (a) the State government agency or agencies that certify public expenditures for waiver services; (b) how it is assured that the CPE is based on the total computable costs for waiver services; and, (c) how the State verifies that the certified public expenditures are eligible for Federal financial participation in accordance with 42 CFR &sect;433.51(b).</span><span id="svapdxI2_2:lbltxtfnaCPEStDscr2" class="outputTextNB em">(Indicate source of revenue for CPEs in Item I-4-a.)</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxI2_2:fnaCPEStDscrChrCntLbl" for="svapdxI2_2:fnaCPEStDscrChrCnt" class="outputLabel"> <span id="svapdxI2_2:fnaCPEStDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxI2_2:fnaCPEStDscrChrCnt" type="text" name="svapdxI2_2:fnaCPEStDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxI2_2:fnaCPEStDscrChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxI2_2:panel_fnaCPEStDscr"><textarea id="svapdxI2_2:fnaCPEStDscr" name="svapdxI2_2:fnaCPEStDscr" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="checkboxGroup"> <input id="svapdxI2_2:fnaCPENonSt" type="checkbox" name="svapdxI2_2:fnaCPENonSt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxI2_2:lbl_fnaCPENonSt" for="svapdxI2_2:fnaCPENonSt" class="outputLabel"> <span id="svapdxI2_2:lbltxt_fnaCPENonSt" class="outputText">Certified Public Expenditures (CPE) of Local Government Agencies.</span></label> </div> <div class="firstIndent"> <p class="outptuTextNB"> <label id="svapdxI2_2:lblfnaCPENonStDscr" for="svapdxI2_2:fnaCPENonStDscr" class="outputLabel"> <span id="svapdxI2_2:lbltxtfnaCPENonStDscr1" class="outputTextNB">Specify: (a) the local government agencies that incur certified public expenditures for waiver services; (b) how it is assured that the CPE is based on total computable costs for waiver services; and, (c) how the State verifies that the certified public expenditures are eligible for Federal financial participation in accordance with 42 CFR &sect;433.51(b). </span><span id="svapdxI2_2:lbltxtfnaCPENonStDscr2" class="outputTextNB em">(Indicate source of revenue for CPEs in Item I-4-b.)</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxI2_2:fnaCPENonStDscrChrCntLbl" for="svapdxI2_2:fnaCPENonStDscrChrCnt" class="outputLabel"> <span id="svapdxI2_2:fnaCPENonStDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxI2_2:fnaCPENonStDscrChrCnt" type="text" name="svapdxI2_2:fnaCPENonStDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxI2_2:fnaCPENonStDscrChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxI2_2:panel_fnaCPENonStDscr"><textarea id="svapdxI2_2:fnaCPENonStDscr" name="svapdxI2_2:fnaCPENonStDscr" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> </div> </li> </ol> <H2 id="pageTitle">Appendix I: Financial Accountability</H2> <H3 id="pageSubTitle">I-2: Rates, Billing and Claims <SPAN id="pageNumber">(3 of 3)</SPAN></H3> <OL class="alphaLC" start="4"> <LI> <p class="outputTextNB"> <strong>Billing Validation Process.</strong> <label id="svapdx2_3:lblfnaBllngValProc" for="svapdx2_3:fnaBllngValProc" class="outputLabel"> <span id="svapdx2_3:lbltxtfnaBllngValProc" class="outputTextNB">Describe the process for validating provider billings to produce the claim for federal financial participation, including the mechanism(s) to assure that all claims for payment are made only: (a) when the individual was eligible for Medicaid waiver payment on the date of service; (b) when the service was included in the participant's approved service plan; and, (c) the services were provided:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdx2_3:fnaBllngValProcChrCntLbl" for="svapdx2_3:fnaBllngValProcChrCnt" class="outputLabel"> <span id="svapdx2_3:fnaBllngValProcChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdx2_3:fnaBllngValProcChrCnt" type="text" name="svapdx2_3:fnaBllngValProcChrCnt" class="chrCnt" size="6" /><span id="svapdx2_3:fnaBllngValProcChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdx2_3:panel_fnaBllngValProc"><textarea id="svapdx2_3:fnaBllngValProc" name="svapdx2_3:fnaBllngValProc" class="inputTextarea" onkeyup="Count(this);" readonly="readonly">Payments are made by the Medicaid agency directly to the providers of waiver and State plan services. There are provider agreements between the DSS and provider of service under the waiver. Payments for all waiver and other State plan services are to be made through an approved Medicaid Management Information System (MMIS). DSS pays providers through the same fiscal agent used in the rest of the Medicaid program. DSS also uses a limited fiscal agent (ACR) who functions only to validate payment of waiver claims, as supported by the participant’s service plan, and submits appropriate claims to Medicaid Management Information System (MMIS) vendor HP, who is a claims payment subcontractor of the Department. Adult Family Living/Foster Care claims are paid to the contracted vendor using the aforementioned process. The agency vendor pays the direct service provider.</textarea></span> </div> </LI> <LI> <p class="outputTextNB"> <strong>Billing and Claims Record Maintenance Requirement.</strong> Records documenting the audit trail of adjudicated claims (including supporting documentation) are maintained by the Medicaid agency, the operating agency (if applicable), and providers of waiver services for a minimum period of 3 years as required in 45 CFR §92.42. </p> </LI> </OL> <H2 id="pageTitle">Appendix I: Financial Accountability</H2> <H3 id="pageSubTitle">I-3: Payment <SPAN id="pageNumber">(1 of 7)</SPAN></H3> <OL class="alphaLC" start="1"> <LI> <p class="outputTextNB"> <strong>Method of payments -- MMIS</strong> (<em>select one</em>): </p> <div class="checkboxGroup"> <label><input id="svapdxI3_1:fnaPymtMMISType:0" type="radio" name="svapdxI3_1:fnaPymtMMISType" checked="checked" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;Payments for all waiver services are made through an approved Medicaid Management Information System (MMIS).</label> </div> <div class="checkboxGroup"> <label><input id="svapdxI3_1:fnaPymtMMISType:1" type="radio" name="svapdxI3_1:fnaPymtMMISType" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;Payments for some, but not all, waiver services are made through an approved MMIS.</label> </div> <div class="firstIndent"> <p class="outputTextNB"> <label id="svapdxI3_1:lblfnaPymtMMISNonProc" for="svapdxI3_1:fnaPymtMMISNonProc" class="outputLabel"> <span id="svapdxI3_1:lbltxtfnaPymtMMISNonProc" class="outputTextNB">Specify: (a) the waiver services that are not paid through an approved MMIS; (b) the process for making such payments and the entity that processes payments; (c) and how an audit trail is maintained for all state and federal funds expended outside the MMIS; and, (d) the basis for the draw of federal funds and claiming of these expenditures on the CMS-64:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxI3_1:fnaPymtMMISNonProcChrCntLbl" for="svapdxI3_1:fnaPymtMMISNonProcChrCnt" class="outputLabel"> <span id="svapdxI3_1:fnaPymtMMISNonProcChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxI3_1:fnaPymtMMISNonProcChrCnt" type="text" name="svapdxI3_1:fnaPymtMMISNonProcChrCnt" class="chrCnt" size="6" /><span id="svapdxI3_1:fnaPymtMMISNonProcChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxI3_1:panel_fnaPymtMMISNonProc"><textarea id="svapdxI3_1:fnaPymtMMISNonProc" name="svapdxI3_1:fnaPymtMMISNonProc" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="checkboxGroup"> <label><input id="svapdxI3_1:fnaPymtMMISType:2" type="radio" name="svapdxI3_1:fnaPymtMMISType" value="2" onclick="return callSave(this, event);" disabled="disabled" />&#160;Payments for waiver services are not made through an approved MMIS.</label> </div> <div class="firstIndent"> <p class="outputTextNB"> <label id="svapdxI3_1:lblfnaPymtMMISNevProc" for="svapdxI3_1:fnaPymtMMISNevProc" class="outputLabel"> <span id="svapdxI3_1:lbltxtfnaPymtMMISNevProc" class="outputTextNB">Specify: (a) the process by which payments are made and the entity that processes payments; (b) how and through which system(s) the payments are processed; (c) how an audit trail is maintained for all state and federal funds expended outside the MMIS; and, (d) the basis for the draw of federal funds and claiming of these expenditures on the CMS-64:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxI3_1:fnaPymtMMISNevProcChrCntLbl" for="svapdxI3_1:fnaPymtMMISNevProcChrCnt" class="outputLabel"> <span id="svapdxI3_1:fnaPymtMMISNevProcChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxI3_1:fnaPymtMMISNevProcChrCnt" type="text" name="svapdxI3_1:fnaPymtMMISNevProcChrCnt" class="chrCnt" size="6" /><span id="svapdxI3_1:fnaPymtMMISNevProcChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxI3_1:panel_fnaPymtMMISNevProc"><textarea id="svapdxI3_1:fnaPymtMMISNevProc" name="svapdxI3_1:fnaPymtMMISNevProc" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="checkboxGroup"> <label><input id="svapdxI3_1:fnaPymtMMISType:3" type="radio" name="svapdxI3_1:fnaPymtMMISType" value="3" onclick="return callSave(this, event);" disabled="disabled" />&#160;Payments for waiver services are made by a managed care entity or entities. The managed care entity is paid a monthly capitated payment per eligible enrollee through an approved MMIS.</label> </div> <div class="firstIndent"> <p class="outputTextNB"> <label id="svapdxI3_1:lblfnaPymtMMISMCProc" for="svapdxI3_1:fnaPymtMMISMCProc" class="outputLabel"> <span id="svapdxI3_1:lbltxtfnaPymtMMISMCProc" class="outputTextNB">Describe how payments are made to the managed care entity or entities:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxI3_1:fnaPymtMMISMCProcChrCntLbl" for="svapdxI3_1:fnaPymtMMISMCProcChrCnt" class="outputLabel"> <span id="svapdxI3_1:fnaPymtMMISMCProcChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxI3_1:fnaPymtMMISMCProcChrCnt" type="text" name="svapdxI3_1:fnaPymtMMISMCProcChrCnt" class="chrCnt" size="6" /><span id="svapdxI3_1:fnaPymtMMISMCProcChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxI3_1:panel_fnaPymtMMISMCProc"><textarea id="svapdxI3_1:fnaPymtMMISMCProc" name="svapdxI3_1:fnaPymtMMISMCProc" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="noShow"><label><input id="svapdxI3_1:fnaPymtMMISType:4" type="radio" name="svapdxI3_1:fnaPymtMMISType" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </LI> </OL> <H2 id="pageTitle">Appendix I: Financial Accountability</H2> <H3 id="pageSubTitle">I-3: Payment <SPAN id="pageNumber">(2 of 7)</SPAN></H3> <OL class="alphaLC" start="2"> <LI> <p class="outputTextNB"><STRONG>Direct payment.</STRONG> In addition to providing that the Medicaid agency makes payments directly to providers of waiver services, payments for waiver services are made utilizing one or more of the following arrangements (<em>select at least one</em>): </p> <div class="checkboxGroup"> <input id="svapdxI3_2:fnaPymtDir" type="checkbox" name="svapdxI3_2:fnaPymtDir" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxI3_2:lblfnaPymtDir" for="svapdxI3_2:fnaPymtDir" class="outputLabel"> <span id="svapdxI3_2:ltltxtfnaPymtDir" class="outputText">The Medicaid agency makes payments directly and does not use a fiscal agent (comprehensive or limited) or a managed care entity or entities.</span></label> </div> <div class="checkboxGroup"> <input id="svapdxI3_2:fnaPymtIndMedAgt" type="checkbox" name="svapdxI3_2:fnaPymtIndMedAgt" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxI3_2:lblfnaPymtIndMedAgt" for="svapdxI3_2:fnaPymtIndMedAgt" class="outputLabel"> <span id="svapdxI3_2:lbltxtfnaPymtIndMedAgt" class="outputText">The Medicaid agency pays providers through the same fiscal agent used for the rest of the Medicaid program.</span></label> </div> <div class="checkboxGroup"> <input id="svapdxI3_2:fnaPymtIndOthAgt" type="checkbox" name="svapdxI3_2:fnaPymtIndOthAgt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxI3_2:lblfnaPymtIndOthAgt" for="svapdxI3_2:fnaPymtIndOthAgt" class="outputLabel"> <span id="svapdxI3_2:lbltxtfnaPymtIndOthAgt" class="outputText">The Medicaid agency pays providers of some or all waiver services through the use of a limited fiscal agent.</span></label> </div> <div class="firstIndent"> <p class="outputTextNB"> <label id="svapdxI3_2:lblfnaPymtIndOthAgtDscr" for="svapdxI3_2:fnaPymtIndOthAgtDscr" class="outputLabel"> <span id="svapdxI3_2:lbltxtfnaPymtIndOthAgtDscr" class="outputTextNB">Specify the limited fiscal agent, the waiver services for which the limited fiscal agent makes payment, the functions that the limited fiscal agent performs in paying waiver claims, and the methods by which the Medicaid agency oversees the operations of the limited fiscal agent:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxI3_2:fnaPymtIndOthAgtDscrChrCntLbl" for="svapdxI3_2:fnaPymtIndOthAgtDscrChrCnt" class="outputLabel"> <span id="svapdxI3_2:fnaPymtIndOthAgtDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxI3_2:fnaPymtIndOthAgtDscrChrCnt" type="text" name="svapdxI3_2:fnaPymtIndOthAgtDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxI3_2:fnaPymtIndOthAgtDscrChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxI3_2:panel_fnaPymtIndOthAgtDscr"><textarea id="svapdxI3_2:fnaPymtIndOthAgtDscr" name="svapdxI3_2:fnaPymtIndOthAgtDscr" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="checkboxGroup"> <input id="svapdxI3_2:fnaPymtIndMCEnt" type="checkbox" name="svapdxI3_2:fnaPymtIndMCEnt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxI3_2:lblfnaPymtIndMCEnt" for="svapdxI3_2:fnaPymtIndMCEnt" class="outputLabel"> <span id="svapdxI3_2:lbltxtfnaPymtIndMCEnt" class="outputText">Providers are paid by a managed care entity or entities for services that are included in the State's contract with the entity.</span></label> </div> <div class="firstIndent"> <p class="outputTextNB"> <label id="svapdxI3_2:lblfnaPymtIndMCEntDscr" for="svapdxI3_2:fnaPymtIndMCEntDscr" class="outputLabel"> <span id="svapdxI3_2:lbltxtfnaPymtIndMCEntDscr" class="outputTextNB">Specify how providers are paid for the services (if any) not included in the State's contract with managed care entities.</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxI3_2:fnaPymtIndMCEntDscrChrCntLbl" for="svapdxI3_2:fnaPymtIndMCEntDscrChrCnt" class="outputLabel"> <span id="svapdxI3_2:fnaPymtIndMCEntDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxI3_2:fnaPymtIndMCEntDscrChrCnt" type="text" name="svapdxI3_2:fnaPymtIndMCEntDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxI3_2:fnaPymtIndMCEntDscrChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxI3_2:panel_fnaPymtIndMCEntDscr"><textarea id="svapdxI3_2:fnaPymtIndMCEntDscr" name="svapdxI3_2:fnaPymtIndMCEntDscr" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> </LI> </OL> <H2 id="pageTitle">Appendix I: Financial Accountability</H2> <H3 id="pageSubTitle">I-3: Payment <SPAN id="pageNumber">(3 of 7)</SPAN></H3> <OL class="alphaLC" start="3"> <LI> <p class="outputTextNB"> <strong>Supplemental or Enhanced Payments.</strong> Section 1902(a)(30) requires that payments for services be consistent with efficiency, economy, and quality of care. Section 1903(a)(1) provides for Federal financial participation to States for expenditures for services under an approved State plan/waiver. Specify whether supplemental or enhanced payments are made. <em>Select one:</em> </p> <table id="svapdxI3_3:fnaPymtSppl" class="selectOneRadio"> <tr> <td> <input type="radio" checked="checked" name="svapdxI3_3:fnaPymtSppl" id="svapdxI3_3:fnaPymtSppl:0" value="0" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxI3_3:fnaPymtSppl:0"> No. The State does not make supplemental or enhanced payments for waiver services.</label></td> </tr> <tr> <td> <input type="radio" name="svapdxI3_3:fnaPymtSppl" id="svapdxI3_3:fnaPymtSppl:1" value="1" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxI3_3:fnaPymtSppl:1"> Yes. The State makes supplemental or enhanced payments for waiver services.</label></td> </tr> </table> <!-- rendered="#{(varFactory.fnaPymtSppl == 1)?true:false}"> --> <div class="firstIndent"> <p class="outputTextNB"> <label id="svapdxI3_3:lblfnaPymtSpplDscr" for="svapdxI3_3:fnaPymtSpplDscr" class="outputLabel"> <span id="svapdxI3_3:lbltxtfnaPymtSpplDscr" class="outputTextNB">Describe: (a) the nature of the supplemental or enhanced payments that are made and the waiver services for which these payments are made; (b) the types of providers to which such payments are made; (c) the source of the non-Federal share of the supplemental or enhanced payment; and, (d) whether providers eligible to receive the supplemental or enhanced payment retain 100% of the total computable expenditure claimed by the State to CMS. Upon request, the State will furnish CMS with detailed information about the total amount of supplemental or enhanced payments to each provider type in the waiver.</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxI3_3:fnaPymtSpplDscrChrCntLbl" for="svapdxI3_3:fnaPymtSpplDscrChrCnt" class="outputLabel"> <span id="svapdxI3_3:fnaPymtSpplDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxI3_3:fnaPymtSpplDscrChrCnt" type="text" name="svapdxI3_3:fnaPymtSpplDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxI3_3:fnaPymtSpplDscrChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxI3_3:panel_fnaPymtSpplDscr"><textarea id="svapdxI3_3:fnaPymtSpplDscr" name="svapdxI3_3:fnaPymtSpplDscr" class="inputTextareaLong" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> </LI> </OL> <H2 id="pageTitle">Appendix I: Financial Accountability</H2> <H3 id="pageSubTitle">I-3: Payment <SPAN id="pageNumber">(4 of 7)</SPAN></H3> <OL class="alphaLC" start="4"> <LI> <p class="outputTextNB"> <strong>Payments to State or Local Government Providers.</strong> <em>Specify whether State or local government providers receive payment for the provision of waiver services.</em> </p> <div class="checkboxGroup"> <label><input id="svapdxI3_4:fnaPymtPub:0" type="radio" name="svapdxI3_4:fnaPymtPub" checked="checked" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;No. State or local government providers do not receive payment for waiver services.</label> <span class="outputTextNB">Do not complete Item I-3-e.</span> </div> <div class="checkboxGroup"> <label><input id="svapdxI3_4:fnaPymtPub:1" type="radio" name="svapdxI3_4:fnaPymtPub" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;Yes. State or local government providers receive payment for waiver services.</label> <span class="outputTextNB">Complete Item I-3-e.</span> </div> <!-- rendered="#{(varFactory.fnaPymtPub == 1)?true:false}"> --> <div class="firstIndent"> <p class="outputTextNB"> <label id="svapdxI3_4:lblfnaPymtPubDscr" for="svapdxI3_4:fnaPymtPubDscr" class="outputLabel"> <span id="svapdxI3_4:lbltxtfnaPymtPubDscr1" class="outputTextNB">Specify the types of State or local government providers that receive payment for waiver services and the services that the State or local government providers furnish: </span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxI3_4:fnaPymtPubDscrChrCntLbl" for="svapdxI3_4:fnaPymtPubDscrChrCnt" class="outputLabel"> <span id="svapdxI3_4:fnaPymtPubDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxI3_4:fnaPymtPubDscrChrCnt" type="text" name="svapdxI3_4:fnaPymtPubDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxI3_4:fnaPymtPubDscrChrCntMax" class="chrCnt"> out of 4000</span> </div> <div class="inputTextareaWA"> <span id="svapdxI3_4:panel_fnaPymtPubDscr"><textarea id="svapdxI3_4:fnaPymtPubDscr" name="svapdxI3_4:fnaPymtPubDscr" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="noShow"> <label><input id="svapdxI3_4:fnaPymtPub:2" type="radio" name="svapdxI3_4:fnaPymtPub" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label> </div> </LI> </OL> <H2 id="pageTitle">Appendix I: Financial Accountability</H2> <H3 id="pageSubTitle">I-3: Payment <SPAN id="pageNumber">(5 of 7)</SPAN></H3> <OL class="alphaLC" start="5"> <LI> <p class="outputTextNB"> <strong>Amount of Payment to State or Local Government Providers.</strong> </p> <!-- rendered="#{(varFactory.fnaPymtPub == '1') ? true : false}"> --> <p class="outputTextNB"> Specify whether any State or local government provider receives payments (including regular and any supplemental payments) that in the aggregate exceed its reasonable costs of providing waiver services and, if so, whether and how the State recoups the excess and returns the Federal share of the excess to CMS on the quarterly expenditure report. <em>Select one:</em> </p> <div class="firstIndent pph underline"> <span id="svapdxI3_5:txt_apdxI3d_no" class="outputText">Answers provided in Appendix I-3-d indicate that you do not need to complete this section.</span> </div> <table id="svapdxI3_5:fnaPymtPubExc" class="selectOneRadio"> <tr> <td> <input type="radio" name="svapdxI3_5:fnaPymtPubExc" id="svapdxI3_5:fnaPymtPubExc:0" value="0" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxI3_5:fnaPymtPubExc:0"> The amount paid to State or local government providers is the same as the amount paid to private providers of the same service.</label></td> </tr> <tr> <td> <input type="radio" name="svapdxI3_5:fnaPymtPubExc" id="svapdxI3_5:fnaPymtPubExc:1" value="1" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxI3_5:fnaPymtPubExc:1"> The amount paid to State or local government providers differs from the amount paid to private providers of the same service. No public provider receives payments that in the aggregate exceed its reasonable costs of providing waiver services.</label></td> </tr> <tr> <td> <input type="radio" name="svapdxI3_5:fnaPymtPubExc" id="svapdxI3_5:fnaPymtPubExc:2" value="2" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxI3_5:fnaPymtPubExc:2"> The amount paid to State or local government providers differs from the amount paid to private providers of the same service. When a State or local government provider receives payments (including regular and any supplemental payments) that in the aggregate exceed the cost of waiver services, the State recoups the excess and returns the federal share of the excess to CMS on the quarterly expenditure report.</label></td> </tr> </table> <div class="firstIndent"> <P class="outputTextNB"> <label id="svapdxI3_5:lblfnaPymtPubExcProc" for="svapdxI3_5:fnaPymtPubExcProc" class="outputLabel"> <span id="svapdxI3_5:lbltxtfnaPymtPubExcProc" class="outputTextNB">Describe the recoupment process:</span></label> </P> <p></p> <div class="chrCntDiv"> <label id="svapdxI3_5:fnaPymtPubExcProcChrCntLbl" for="svapdxI3_5:fnaPymtPubExcProcChrCnt" class="outputLabel"> <span id="svapdxI3_5:fnaPymtPubExcProcChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxI3_5:fnaPymtPubExcProcChrCnt" type="text" name="svapdxI3_5:fnaPymtPubExcProcChrCnt" class="chrCnt" size="6" /><span id="svapdxI3_5:fnaPymtPubExcProcChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxI3_5:panel_fnaPymtPubExcProc"><textarea id="svapdxI3_5:fnaPymtPubExcProc" name="svapdxI3_5:fnaPymtPubExcProc" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> </LI> </OL> <H2 id="pageTitle">Appendix I: Financial Accountability</H2> <H3 id="pageSubTitle">I-3: Payment <SPAN id="pageNumber">(6 of 7)</SPAN></H3> <OL class="alphaLC" start="6"> <LI> <p class="outputTextNB"> <strong>Provider Retention of Payments.</strong> Section 1903(a)(1) provides that Federal matching funds are only available for expenditures made by states for services under the approved waiver. <em>Select one:</em> </p> <div class="checkboxGroup"> <label><input id="svapdxI3_6:fnaPymtPrvdrRet:0" type="radio" name="svapdxI3_6:fnaPymtPrvdrRet" checked="checked" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;Providers receive and retain 100 percent of the amount claimed to CMS for waiver services.</label> </div> <div class="noShow"> <label><input id="svapdxI3_6:fnaPymtPrvdrRet:1" type="radio" name="svapdxI3_6:fnaPymtPrvdrRet" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;Providers do not receive and retain 100 percent of the amount claimed to CMS for waiver services.</label> </div> <div class="noShow"> <p class="outputTextNB"> <label id="svapdxI3_6:lblfnaPymtPrvdrRetDscr" for="svapdxI3_6:fnaPymtPrvdrRetDscr" class="outputLabel"> <span id="svapdxI3_6:lbltxtfnaPymtPrvdrRetDscr" class="outputTextNB">Provide a full description of the billing, claims, or payment processes that result in less than 100% reimbursement of providers. Include: (a) the methodology for reduced or returned payments; (b) a complete listing of types of providers, the amount or percentage of payments that are reduced or returned; and, (c) the disposition and use of the funds retained or returned to the State (i.e., general fund, medical services account, etc.):</span></label> </p> <p></p> <div class="noShow"> <label id="svapdxI3_6:fnaPymtPrvdrRetDscrChrCntLbl" for="svapdxI3_6:fnaPymtPrvdrRetDscrChrCnt" class="outputLabel"> <span id="svapdxI3_6:fnaPymtPrvdrRetDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxI3_6:fnaPymtPrvdrRetDscrChrCnt" type="text" name="svapdxI3_6:fnaPymtPrvdrRetDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxI3_6:fnaPymtPrvdrRetDscrChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="noShow"> <span id="svapdxI3_6:panel_fnaPymtPrvdrRetDscr"><textarea id="svapdxI3_6:fnaPymtPrvdrRetDscr" name="svapdxI3_6:fnaPymtPrvdrRetDscr" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="checkboxGroup"> <label><input id="svapdxI3_6:fnaPymtPrvdrRet:2" type="radio" name="svapdxI3_6:fnaPymtPrvdrRet" value="2" onclick="return callSave(this, event);" disabled="disabled" />&#160;Providers are paid by a managed care entity (or entities) that is paid a monthly capitated payment.</label> </div> <div class="firstIndent"> <p class="outputTextNB"> <label id="svapdxI3_6:lblfnaPymtPrvdrRetMCDscr" for="svapdxI3_6:fnaPymtPrvdrRetMCDscr" class="outputLabel"> <span id="svapdxI3_6:lbltxtfnaPymtPrvdrRetMCDscr" class="outputTextNB">Specify whether the monthly capitated payment to managed care entities is reduced or returned in part to the State.</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxI3_6:fnaPymtPrvdrRetMCDscrChrCntLbl" for="svapdxI3_6:fnaPymtPrvdrRetMCDscrChrCnt" class="outputLabel"> <span id="svapdxI3_6:fnaPymtPrvdrRetMCDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxI3_6:fnaPymtPrvdrRetMCDscrChrCnt" type="text" name="svapdxI3_6:fnaPymtPrvdrRetMCDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxI3_6:fnaPymtPrvdrRetMCDscrChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxI3_6:panel_fnaPymtPrvdrRetMCDscr"><textarea id="svapdxI3_6:fnaPymtPrvdrRetMCDscr" name="svapdxI3_6:fnaPymtPrvdrRetMCDscr" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="noShow"><label><input id="svapdxI3_6:fnaPymtPrvdrRet:3" type="radio" name="svapdxI3_6:fnaPymtPrvdrRet" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </LI> </OL> <H2 id="pageTitle">Appendix I: Financial Accountability</H2> <H3 id="pageSubTitle">I-3: Payment <SPAN id="pageNumber">(7 of 7)</SPAN></H3> <OL class="alphaLC" start="7"> <LI> <p class="outputTextNB"><strong>Additional Payment Arrangements</strong></p> <OL class="romanLC" start="1"> <LI> <p class="outputTextNB"> <strong>Voluntary Reassignment of Payments to a Governmental Agency.</strong> <em>Select one:</em> </p> <table id="svapdxI3_7:fnaPymtVolReass" class="selectOneRadio"> <tr> <td> <input type="radio" checked="checked" name="svapdxI3_7:fnaPymtVolReass" id="svapdxI3_7:fnaPymtVolReass:0" value="0" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxI3_7:fnaPymtVolReass:0"> No. The State does not provide that providers may voluntarily reassign their right to direct payments to a governmental agency.</label></td> </tr> <tr> <td> <input type="radio" name="svapdxI3_7:fnaPymtVolReass" id="svapdxI3_7:fnaPymtVolReass:1" value="1" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxI3_7:fnaPymtVolReass:1"> Yes. Providers may voluntarily reassign their right to direct payments to a governmental agency as provided in 42 CFR &sect;447.10(e).</label></td> </tr> </table> <div class="firstIndent"> <p class="outputTextNB"> <label id="svapdxI3_7:lblfnaPymtVolReassEnt" for="svapdxI3_7:fnaPymtVolReassEnt" class="outputLabel"> <span id="svapdxI3_7:lbltxtfnaPymtVolReassEnt" class="outputTextNB">Specify the governmental agency (or agencies) to which reassignment may be made.</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxI3_7:fnaPymtVolReassEntChrCntLbl" for="svapdxI3_7:fnaPymtVolReassEntChrCnt" class="outputLabel"> <span id="svapdxI3_7:fnaPymtVolReassEntChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxI3_7:fnaPymtVolReassEntChrCnt" type="text" name="svapdxI3_7:fnaPymtVolReassEntChrCnt" class="chrCnt" size="6" /><span id="svapdxI3_7:fnaPymtVolReassEntChrCntMax" class="chrCnt"> out of 4000</span> </div> <div class="inputTextareaWA"> <span id="svapdxI3_7:panel_fnaPymtVolReassEnt"><textarea id="svapdxI3_7:fnaPymtVolReassEnt" name="svapdxI3_7:fnaPymtVolReassEnt" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> </LI> <LI> <p class="outputTextNB"> <strong>Organized Health Care Delivery System.</strong> <em>Select one:</em> </p> <table id="svapdxI3_7:fnaPymtOHCDS" class="selectOneRadio"> <tr> <td> <input type="radio" checked="checked" name="svapdxI3_7:fnaPymtOHCDS" id="svapdxI3_7:fnaPymtOHCDS:0" value="0" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxI3_7:fnaPymtOHCDS:0"> No. The State does not employ Organized Health Care Delivery System (OHCDS) arrangements under the provisions of 42 CFR &sect;447.10.</label></td> </tr> <tr> <td> <input type="radio" name="svapdxI3_7:fnaPymtOHCDS" id="svapdxI3_7:fnaPymtOHCDS:1" value="1" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxI3_7:fnaPymtOHCDS:1"> Yes. The waiver provides for the use of Organized Health Care Delivery System arrangements under the provisions of 42 CFR &sect;447.10.</label></td> </tr> </table> <div class="firstIndent"> <P class="outputTextNB"> <label id="svapdxI3_7:lblfnaPymtOHCDSDscr" for="svapdxI3_7:fnaPymtOHCDSDscr" class="outputLabel"> <span id="svapdxI3_7:lbltxtfnaPymtOHCDSDscr" class="outputTextNB">Specify the following: (a) the entities that are designated as an OHCDS and how these entities qualify for designation as an OHCDS; (b) the procedures for direct provider enrollment when a provider does not voluntarily agree to contract with a designated OHCDS; (c) the method(s) for assuring that participants have free choice of qualified providers when an OHCDS arrangement is employed, including the selection of providers not affiliated with the OHCDS; (d) the method(s) for assuring that providers that furnish services under contract with an OHCDS meet applicable provider qualifications under the waiver; (e) how it is assured that OHCDS contracts with providers meet applicable requirements; and, (f) how financial accountability is assured when an OHCDS arrangement is used:</span></label> </P> <p></p> <div class="chrCntDiv"> <label id="svapdxI3_7:fnaPymtOHCDSDscrChrCntLbl" for="svapdxI3_7:fnaPymtOHCDSDscrChrCnt" class="outputLabel"> <span id="svapdxI3_7:fnaPymtOHCDSDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxI3_7:fnaPymtOHCDSDscrChrCnt" type="text" name="svapdxI3_7:fnaPymtOHCDSDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxI3_7:fnaPymtOHCDSDscrChrCntMax" class="chrCnt"> out of 18000</span> </div> <div class="inputTextareaWA"> <span id="svapdxI3_7:panel_fnaPymtOHCDSDscr"><textarea id="svapdxI3_7:fnaPymtOHCDSDscr" name="svapdxI3_7:fnaPymtOHCDSDscr" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> </LI> <LI> <p class="outputTextNB"> <strong>Contracts with MCOs, PIHPs or PAHPs.</strong> <em>Select one:</em> </p> <div class="checkboxGroup"><label><input id="svapdxI3_7:fnaPymtPHP:2" type="radio" name="svapdxI3_7:fnaPymtPHP" checked="checked" value="2" onclick="return callSave(this, event);" disabled="disabled" />&#160;The State does not contract with MCOs, PIHPs or PAHPs for the provision of waiver services.</label></div> <div class="checkboxGroup"><label><input id="svapdxI3_7:fnaPymtPHP:0" type="radio" name="svapdxI3_7:fnaPymtPHP" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;The State contracts with a Managed Care Organization(s) (MCOs) and/or prepaid inpatient health plan(s) (PIHP) or prepaid ambulatory health plan(s) (PAHP) under the provisions of &sect;1915(a)(1) of the Act for the delivery of waiver and other services. Participants may voluntarily elect to receive waiver and other services through such MCOs or prepaid health plans. Contracts with these health plans are on file at the State Medicaid agency.</label></div> <div class="firstIndent"> <p class="outputTextNB"> <label id="svapdxI3_7:lblfnaPymtPHPDscr" for="svapdxI3_7:fnaPymtPHPDscr" class="outputLabel"> <span id="svapdxI3_7:lbltxtfnaPymtPHPDscr" class="outputTextNB">Describe: (a) the MCOs and/or health plans that furnish services under the provisions of &sect;1915(a)(1); (b) the geographic areas served by these plans; (c) the waiver and other services furnished by these plans; and, (d) how payments are made to the health plans.</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxI3_7:fnaPymtPHPDscrChrCntLbl" for="svapdxI3_7:fnaPymtPHPDscrChrCnt" class="outputLabel"> <span id="svapdxI3_7:fnaPymtPHPDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxI3_7:fnaPymtPHPDscrChrCnt" type="text" name="svapdxI3_7:fnaPymtPHPDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxI3_7:fnaPymtPHPDscrChrCntMax" class="chrCnt"> out of 18000</span> </div> <div class="inputTextareaWA"> <span id="svapdxI3_7:panel_fnaPymtPHPDscr"><textarea id="svapdxI3_7:fnaPymtPHPDscr" name="svapdxI3_7:fnaPymtPHPDscr" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="checkboxGroup"><label><input id="svapdxI3_7:fnaPymtPHP:1" type="radio" name="svapdxI3_7:fnaPymtPHP" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;This waiver is a part of a concurrent &sect;1915(b)/&sect;1915(c) waiver. Participants are required to obtain waiver and other services through a MCO and/or prepaid inpatient health plan (PIHP) or a prepaid ambulatory health plan (PAHP). The &sect;1915(b) waiver specifies the types of health plans that are used and how payments to these plans are made.</label></div> <!-- Peshal added --> <div class="checkboxGroup"><label><input id="svapdxI3_7:fnaPymtPHP:3" type="radio" name="svapdxI3_7:fnaPymtPHP" value="3" onclick="return callSave(this, event);" disabled="disabled" />&#160;This waiver is a part of a concurrent &#65533;1115/&#65533;1915(c) waiver. Participants are required to obtain waiver and other services through a MCO and/or prepaid inpatient health plan (PIHP) or a prepaid ambulatory health plan (PAHP). The &#65533;1115 waiver specifies the types of health plans that are used and how payments to these plans are made.</label></div> <div class="noShow"><label><input id="svapdxI3_7:fnaPymtPHP:4" type="radio" name="svapdxI3_7:fnaPymtPHP" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </LI> </OL> </LI> </OL> <H2 id="pageTitle">Appendix I: Financial Accountability</H2> <H3 id="pageSubTitle">I-4: Non-Federal Matching Funds <SPAN id="pageNumber">(1 of 3)</SPAN></H3> <OL class="alphaLC" start="1"> <LI> <p class="outputTextNB"> <strong>State Level Source(s) of the Non-Federal Share of Computable Waiver Costs.</strong> Specify the State source or sources of the non-federal share of computable waiver costs. <EM>Select at least one</EM>: </p> <div class="checkboxGroup"> <input id="svapdxI4_1:fnaOthFnStTxMed" type="checkbox" name="svapdxI4_1:fnaOthFnStTxMed" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxI4_1:lblfnaOthFnStTxMed" for="svapdxI4_1:fnaOthFnStTxMed" class="outputLabel"> <span id="svapdxI4_1:lbltxtfnaOthFnStTxMed" class="outputText">Appropriation of State Tax Revenues to the State Medicaid agency</span></label> </div> <div class="checkboxGroup"> <input id="svapdxI4_1:fnaOthFnStTxNonMed" type="checkbox" name="svapdxI4_1:fnaOthFnStTxNonMed" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxI4_1:lblfnaOthFnStTxNonMed" for="svapdxI4_1:fnaOthFnStTxNonMed" class="outputLabel"> <span id="svapdxI4_1:lbltxtfnaOthFnStTxNonMed" class="outputText">Appropriation of State Tax Revenues to a State Agency other than the Medicaid Agency.</span></label> </div> <div class="firstIndent"> <p class="outputTextNB"> <label id="svapdxI4_1:lblfnaOthFnStTxNonMedProc" for="svapdxI4_1:fnaOthFnStTxNonMedProc" class="outputLabel"> <span id="svapdxI4_1:lbltxtfnaOthFnStTxNonMedProc" class="outputTextNB">If the source of the non-federal share is appropriations to another state agency (or agencies), specify: (a) the State entity or agency receiving appropriated funds and (b) the mechanism that is used to transfer the funds to the Medicaid Agency or Fiscal Agent, such as an Intergovernmental Transfer (IGT), including any matching arrangement, and/or, indicate if the funds are directly expended by State agencies as CPEs, as indicated in Item I-2-c:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxI4_1:fnaOthFnStTxNonMedProcChrCntLbl" for="svapdxI4_1:fnaOthFnStTxNonMedProcChrCnt" class="outputLabel"> <span id="svapdxI4_1:fnaOthFnStTxNonMedProcChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxI4_1:fnaOthFnStTxNonMedProcChrCnt" type="text" name="svapdxI4_1:fnaOthFnStTxNonMedProcChrCnt" class="chrCnt" size="6" /><span id="svapdxI4_1:fnaOthFnStTxNonMedProcChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxI4_1:panel_fnaOthFnStTxNonMedProc"><textarea id="svapdxI4_1:fnaOthFnStTxNonMedProc" name="svapdxI4_1:fnaOthFnStTxNonMedProc" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="checkboxGroup"> <input id="svapdxI4_1:fnaOthFnStOth" type="checkbox" name="svapdxI4_1:fnaOthFnStOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxI4_1:lblfnaOthFnStOth" for="svapdxI4_1:fnaOthFnStOth" class="outputLabel"> <span id="svapdxI4_1:lbltxtfnaOthFnStOth" class="outputText">Other State Level Source(s) of Funds.</span></label> </div> <div class="firstIndent"> <p class="outputTextNB"> <label id="svapdxI4_1:lblfnaOthFnStOthProc" for="svapdxI4_1:fnaOthFnStOthProc" class="outputLabel"> <span id="svapdxI4_1:lbltxtfnaOthFnStOthProc" class="outputTextNB">Specify: (a) the source and nature of funds; (b) the entity or agency that receives the funds; and, (c) the mechanism that is used to transfer the funds to the Medicaid Agency or Fiscal Agent, such as an Intergovernmental Transfer (IGT), including any matching arrangement, and/or, indicate if funds are directly expended by State agencies as CPEs, as indicated in Item I-2-c:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxI4_1:fnaOthFnStOthProcChrCntLbl" for="svapdxI4_1:fnaOthFnStOthProcChrCnt" class="outputLabel"> <span id="svapdxI4_1:fnaOthFnStOthProcChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxI4_1:fnaOthFnStOthProcChrCnt" type="text" name="svapdxI4_1:fnaOthFnStOthProcChrCnt" class="chrCnt" size="6" /><span id="svapdxI4_1:fnaOthFnStOthProcChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxI4_1:panel_fnaOthFnStOthProc"><textarea id="svapdxI4_1:fnaOthFnStOthProc" name="svapdxI4_1:fnaOthFnStOthProc" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> </LI> </OL> <H2 id="pageTitle">Appendix I: Financial Accountability</H2> <H3 id="pageSubTitle">I-4: Non-Federal Matching Funds <SPAN id="pageNumber">(2 of 3)</SPAN></H3> <OL class="alphaLC" start="2"> <LI> <p class="outputTextNB"> <strong>Local Government or Other Source(s) of the Non-Federal Share of Computable Waiver Costs.</strong> Specify the source or sources of the non-federal share of computable waiver costs that are not from state sources. <em>Select One</em>: </p> <div class="checkboxGroup"><label><input id="svapdxI4_2:fnaOthFnLoc:0" type="radio" name="svapdxI4_2:fnaOthFnLoc" checked="checked" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;Not Applicable</label><span id="svapdxI4_2:lbltxtfnaOthFnLoc_0" class="outputTextNB">. There are no local government level sources of funds utilized as the non-federal share.</span></div> <div class="checkboxGroup"><label><input id="svapdxI4_2:fnaOthFnLoc:1" type="radio" name="svapdxI4_2:fnaOthFnLoc" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;Applicable</label></div> <div class="firstIndent"> <div class="outputTextNB"><em>Check each that applies:</em></div> <div class="noShow checkboxGroup"> <input id="svapdxI4_2:fnaOthFnLocNa" type="checkbox" name="svapdxI4_2:fnaOthFnLocNa" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxI4_2:lblfnaOthFnLocNa" for="svapdxI4_2:fnaOthFnLocNa" class="outputLabel"> <span id="svapdxI4_2:lbltxtfnaOthFnLocNa" class="outputText">Not Applicable. There are no non-State level sources of funds for the non-federal share.</span></label> </div> <div class="checkboxGroup"> <input id="svapdxI4_2:fnaOthFnLocRev" type="checkbox" name="svapdxI4_2:fnaOthFnLocRev" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxI4_2:lblfnaOthFnLocRev" for="svapdxI4_2:fnaOthFnLocRev" class="outputLabel"> <span id="svapdxI4_2:lbltxtfnaOthFnLocRev" class="outputText">Appropriation of Local Government Revenues.</span></label> </div> <div class="firstIndent"> <p class="outputTextNB"> <label id="svapdxI4_2:lblfnaOthFnLocRevProc" for="svapdxI4_2:fnaOthFnLocRevProc" class="outputLabel"> <span id="svapdxI4_2:lbltxtfnaOthFnLocRevProc" class="outputTextNB">Specify: (a) the local government entity or entities that have the authority to levy taxes or other revenues; (b) the source(s) of revenue; and, (c) the mechanism that is used to transfer the funds to the Medicaid Agency or Fiscal Agent, such as an Intergovernmental Transfer (IGT), including any matching arrangement (indicate any intervening entities in the transfer process), and/or, indicate if funds are directly expended by local government agencies as CPEs, as specified in Item I-2-c:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxI4_2:fnaOthFnLocRevProcChrCntLbl" for="svapdxI4_2:fnaOthFnLocRevProcChrCnt" class="outputLabel"> <span id="svapdxI4_2:fnaOthFnLocRevProcChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxI4_2:fnaOthFnLocRevProcChrCnt" type="text" name="svapdxI4_2:fnaOthFnLocRevProcChrCnt" class="chrCnt" size="6" /><span id="svapdxI4_2:fnaOthFnLocRevProcChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxI4_2:panel_fnaOthFnLocRevProc"><textarea id="svapdxI4_2:fnaOthFnLocRevProc" name="svapdxI4_2:fnaOthFnLocRevProc" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> <div class="checkboxGroup"> <input id="svapdxI4_2:fnaOthFnLocOth" type="checkbox" name="svapdxI4_2:fnaOthFnLocOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxI4_2:lblfnaOthFnLocOth" for="svapdxI4_2:fnaOthFnLocOth" class="outputLabel"> <span id="svapdxI4_2:lbltxtfnaOthFnLocOth" class="outputText">Other Local Government Level Source(s) of Funds.</span></label> </div> <div class="firstIndent"> <p class="outputTextNB"> <label id="svapdxI4_2:lblfnaOthFnLocOthProc" for="svapdxI4_2:fnaOthFnLocOthProc" class="outputLabel"> <span id="svapdxI4_2:lbltxtfnaOthFnLocOthProc" class="outputTextNB">Specify: (a) the source of funds; (b) the local government entity or agency receiving funds; and, (c) the mechanism that is used to transfer the funds to the State Medicaid Agency or Fiscal Agent, such as an Intergovernmental Transfer (IGT), including any matching arrangement, and/or, indicate if funds are directly expended by local government agencies as CPEs, as specified in Item I-2-c:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxI4_2:fnaOthFnLocOthProcChrCntLbl" for="svapdxI4_2:fnaOthFnLocOthProcChrCnt" class="outputLabel"> <span id="svapdxI4_2:fnaOthFnLocOthProcChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxI4_2:fnaOthFnLocOthProcChrCnt" type="text" name="svapdxI4_2:fnaOthFnLocOthProcChrCnt" class="chrCnt" size="6" /><span id="svapdxI4_2:fnaOthFnLocOthProcChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxI4_2:panel_fnaOthFnLocOthProc"><textarea id="svapdxI4_2:fnaOthFnLocOthProc" name="svapdxI4_2:fnaOthFnLocOthProc" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> </div> <div class="noShow"><label><input id="svapdxI4_2:fnaOthFnLoc:2" type="radio" name="svapdxI4_2:fnaOthFnLoc" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </LI> </OL> <H2 id="pageTitle">Appendix I: Financial Accountability</H2> <H3 id="pageSubTitle">I-4: Non-Federal Matching Funds <SPAN id="pageNumber">(3 of 3)</SPAN></H3> <OL class="alphaLC" start="3"> <LI> <p class="outputTextNB"> <strong>Information Concerning Certain Sources of Funds.</strong> Indicate whether any of the funds listed in Items I-4-a or I-4-b that make up the non-federal share of computable waiver costs come from the following sources: (a) health care-related taxes or fees; (b) provider-related donations; and/or, (c) federal funds. <em>Select one</em>: </p> <div class="checkboxGroup"><label><input id="svapdxI4_3:fnaOthFn:0" type="radio" name="svapdxI4_3:fnaOthFn" checked="checked" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;None of the specified sources of funds contribute to the non-federal share of computable waiver costs</label></div> <div class="checkboxGroup"><label><input id="svapdxI4_3:fnaOthFn:1" type="radio" name="svapdxI4_3:fnaOthFn" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;The following source(s) are used</label></div> <div class="firstIndent"> <div class="outputTextNB"><em>Check each that applies:</em></div> <div class="noShow"> <input id="svapdxI4_3:fnaOthFnNa" type="checkbox" name="svapdxI4_3:fnaOthFnNa" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxI4_3:lblfnaOthFnNa" for="svapdxI4_3:fnaOthFnNa" class="outputLabel"> <span id="svapdxI4_3:lbltxtfnaOthFnNa" class="outputText">None of the foregoing sources of funds contribute to the non-federal share of computable waiver costs.</span></label> </div> <div class="checkboxGroup"> <input id="svapdxI4_3:fnaOthFnPrvdrFee" type="checkbox" name="svapdxI4_3:fnaOthFnPrvdrFee" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxI4_3:lblfnaOthFnPrvdrFee" for="svapdxI4_3:fnaOthFnPrvdrFee" class="outputLabel"> <span id="svapdxI4_3:lbltxtfnaOthFnPrvdrFee" class="outputText">Health care-related taxes or fees</span></label> </div> <div class="checkboxGroup"> <input id="svapdxI4_3:fnaOthFnPrvdrDon" type="checkbox" name="svapdxI4_3:fnaOthFnPrvdrDon" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxI4_3:lblfnaOthFnPrvdrDon" for="svapdxI4_3:fnaOthFnPrvdrDon" class="outputLabel"> <span id="svapdxI4_3:lbltxtfnaOthFnPrvdrDon" class="outputText">Provider-related donations</span></label> </div> <div class="checkboxGroup"> <input id="svapdxI4_3:fnaOthFnFed" type="checkbox" name="svapdxI4_3:fnaOthFnFed" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxI4_3:lblfnaOthFnFed" for="svapdxI4_3:fnaOthFnFed" class="outputLabel"> <span id="svapdxI4_3:lbltxtfnaOthFnFed" class="outputText">Federal funds</span></label> </div> <div> <p class="outputTextNB"> <label id="svapdxI4_3:lblfnaOthFnFedDscr" for="svapdxI4_3:fnaOthFnFedDscr" class="outputLabel"> <span id="svapdxI4_3:lbltxtfnaOthFnFedDscr" class="outputTextNB">For each source of funds indicated above, describe the source of the funds in detail:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxI4_3:fnaOthFnFedDscrChrCntLbl" for="svapdxI4_3:fnaOthFnFedDscrChrCnt" class="outputLabel"> <span id="svapdxI4_3:fnaOthFnFedDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxI4_3:fnaOthFnFedDscrChrCnt" type="text" name="svapdxI4_3:fnaOthFnFedDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxI4_3:fnaOthFnFedDscrChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxI4_3:panel_fnaOthFnFedDscr"><textarea id="svapdxI4_3:fnaOthFnFedDscr" name="svapdxI4_3:fnaOthFnFedDscr" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> </div> <div class="noShow"><label><input id="svapdxI4_3:fnaOthFn:2" type="radio" name="svapdxI4_3:fnaOthFn" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </LI> </OL> <H2 id="pageTitle">Appendix I: Financial Accountability</H2> <H3 id="pageSubTitle">I-5: Exclusion of Medicaid Payment for Room and Board <SPAN id="pageNumber"></SPAN></H3> <OL class="alphaLC" start="1" id="apdxI5_1_ol"> <LI id="apdxI5_1_li_a"> <p class="outputTextNB"> <strong>Services Furnished in Residential Settings.</strong> <em>Select one:</em> </p> <div class="checkboxGroup"> <label><input id="svapdxI5_1:fnaNonPerResSvc:0" type="radio" name="svapdxI5_1:fnaNonPerResSvc" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;No services under this waiver are furnished in residential settings other than the private residence of the individual.</label> </div> <div class="checkboxGroup"> <label><input id="svapdxI5_1:fnaNonPerResSvc:1" type="radio" name="svapdxI5_1:fnaNonPerResSvc" checked="checked" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;As specified in Appendix C, the State furnishes waiver services in residential settings other than the personal home of the individual.</label> </div> <div class="noShow"><label><input id="svapdxI5_1:fnaNonPerResSvc:2" type="radio" name="svapdxI5_1:fnaNonPerResSvc" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </LI> <LI id="apdxI5_1_li_b"> <div id="i5b_label" class="outputTextNB"> <strong>Method for Excluding the Cost of Room and Board Furnished in Residential Settings.</strong> <label id="svapdxI5_1:lblfnaNonPerResSvcDscr" for="svapdxI5_1:fnaNonPerResSvcDscr" class="outputLabel"> <span id="svapdxI5_1:lbltxtfnaNonPerResSvcDscr" class="outputTextNB">The following describes the methodology that the State uses to exclude Medicaid payment for room and board in residential settings:</span></label> </div> <p></p> <div class="chrCntDiv"> <label id="svapdxI5_1:fnaNonPerResSvcDscrChrCntLbl" for="svapdxI5_1:fnaNonPerResSvcDscrChrCnt" class="outputLabel"> <span id="svapdxI5_1:fnaNonPerResSvcDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxI5_1:fnaNonPerResSvcDscrChrCnt" type="text" name="svapdxI5_1:fnaNonPerResSvcDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxI5_1:fnaNonPerResSvcDscrChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxI5_1:panel_fnaNonPerResSvcDscr"><textarea id="svapdxI5_1:fnaNonPerResSvcDscr" name="svapdxI5_1:fnaNonPerResSvcDscr" class="inputTextareaLong" onkeyup="Count(this);" readonly="readonly">Room and board shall be excluded from the rate for Adult Family Living. Room and board shall be excluded from the rate for Adult Family Living/Foster Care. If they reside in the caregiver's home, the room and board amount is determined between the participant and the caregiver. The payment for the waiver service is not part of that negotiation. The waiver rate is based on the participants' assessed needs.</textarea></span> </div> </LI> </OL> <H2 id="pageTitle">Appendix I: Financial Accountability</H2> <H3 id="pageSubTitle">I-6: Payment for Rent and Food Expenses of an Unrelated Live-In Caregiver <SPAN id="pageNumber"></SPAN></H3> <div class="firstIndent"> <p class="outputTextNB"> <strong>Reimbursement for the Rent and Food Expenses of an Unrelated Live-In Personal Caregiver.</strong> <em>Select one:</em> </p> <table id="svapdxI6_1:fnaFFP" class="selectOneRadio"> <tr> <td> <input type="radio" checked="checked" name="svapdxI6_1:fnaFFP" id="svapdxI6_1:fnaFFP:0" value="0" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxI6_1:fnaFFP:0"> No. The State does not reimburse for the rent and food expenses of an unrelated live-in personal caregiver who resides in the same household as the participant.</label></td> </tr> <tr> <td> <input type="radio" name="svapdxI6_1:fnaFFP" id="svapdxI6_1:fnaFFP:1" value="1" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxI6_1:fnaFFP:1"> Yes. Per 42 CFR &sect;441.310(a)(2)(ii), the State will claim FFP for the additional costs of rent and food that can be reasonably attributed to an unrelated live-in personal caregiver who resides in the same household as the waiver participant. The State describes its coverage of live-in caregiver in Appendix C-3 and the costs attributable to rent and food for the live-in caregiver are reflected separately in the computation of factor D (cost of waiver services) in Appendix J. FFP for rent and food for a live-in caregiver will not be claimed when the participant lives in the caregiver's home or in a residence that is owned or leased by the provider of Medicaid services.</label></td> </tr> </table> <div class="firstIndent"> <p class="outputTextNB"> <label id="svapdxI6_1:lblfnaFFPMth" for="svapdxI6_1:fnaFFPMth" class="outputLabel"> <span id="svapdxI6_1:lbltxtfnaFFPMth" class="outputTextNB">The following is an explanation of: (a) the method used to apportion the additional costs of rent and food attributable to the unrelated live-in personal caregiver that are incurred by the individual served on the waiver and (b) the method used to reimburse these costs:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxI6_1:fnaFFPMthChrCntLbl" for="svapdxI6_1:fnaFFPMthChrCnt" class="outputLabel"> <span id="svapdxI6_1:fnaFFPMthChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxI6_1:fnaFFPMthChrCnt" type="text" name="svapdxI6_1:fnaFFPMthChrCnt" class="chrCnt" size="6" /><span id="svapdxI6_1:fnaFFPMthChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxI6_1:panel_fnaFFPMth"><textarea id="svapdxI6_1:fnaFFPMth" name="svapdxI6_1:fnaFFPMth" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> </div> <H2 id="pageTitle">Appendix I: Financial Accountability</H2> <H3 id="pageSubTitle">I-7: Participant Co-Payments for Waiver Services and Other Cost Sharing <SPAN id="pageNumber">(1 of 5)</SPAN></H3> <OL class="alphaLC" start="1" id="ol_I7"> <LI id="li_I7a"> <p class="outputTextNB"> <strong>Co-Payment Requirements.</strong> Specify whether the State imposes a co-payment or similar charge upon waiver participants for waiver services. These charges are calculated per service and have the effect of reducing the total computable claim for federal financial participation. <em>Select one:</em> </p> <div class="checkboxGroup"> <label><input id="svapdxI7_1:fnaCoPayReq:0" type="radio" name="svapdxI7_1:fnaCoPayReq" checked="checked" value="0" onclick="return callSave(this, event);" disabled="disabled" />&#160;No. The State does not impose a co-payment or similar charge upon participants for waiver services.</label> </div> <div class="checkboxGroup"> <label><input id="svapdxI7_1:fnaCoPayReq:1" type="radio" name="svapdxI7_1:fnaCoPayReq" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;Yes. The State imposes a co-payment or similar charge upon participants for one or more waiver services.</label> </div> <div class="firstIndent"> <OL class="romanLC" start="1" id="ol_I7a"> <LI id="li_I7ai"> <p class="outputTextNB"><strong>Co-Pay Arrangement.</strong></p> <!-- rendered="#{(varFactory.fnaCoPayReq == '1')?true:false}"> --> <p class="outputTextNB">Specify the types of co-pay arrangements that are imposed on waiver participants (<em>check each that applies</em>):</p> <p class="outputTextNB underline"><em><strong>Charges Associated with the Provision of Waiver Services</strong> (if any are checked, complete Items I-7-a-ii through I-7-a-iv):</em></p> <div class="checkboxGroup"> <input id="svapdxI7_1:fnaCoPayNomDed" type="checkbox" name="svapdxI7_1:fnaCoPayNomDed" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxI7_1:lblfnaCoPayNomDed" for="svapdxI7_1:fnaCoPayNomDed" class="outputLabel"> <span id="svapdxI7_1:lbltxtfnaCoPayNomDed" class="outputText">Nominal deductible</span></label> </div> <div class="checkboxGroup"> <input id="svapdxI7_1:fnaCoPayCoIns" type="checkbox" name="svapdxI7_1:fnaCoPayCoIns" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxI7_1:lblfnaCoPayCoIns" for="svapdxI7_1:fnaCoPayCoIns" class="outputLabel"> <span id="svapdxI7_1:lbltxtfnaCoPayCoIns" class="outputText">Coinsurance</span></label> </div> <div class="checkboxGroup"> <input id="svapdxI7_1:fnaCoPayCoPay" type="checkbox" name="svapdxI7_1:fnaCoPayCoPay" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxI7_1:lblfnaCoPayCoPay" for="svapdxI7_1:fnaCoPayCoPay" class="outputLabel"> <span id="svapdxI7_1:lbltxtfnaCoPayCoPay" class="outputText">Co-Payment</span></label> </div> <div class="checkboxGroup"> <input id="svapdxI7_1:fnaCoPayOth" type="checkbox" name="svapdxI7_1:fnaCoPayOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxI7_1:lblfnaCoPayOth" for="svapdxI7_1:fnaCoPayOth" class="outputLabel"> <span id="svapdxI7_1:lbltxtfnaCoPayOth" class="outputText">Other charge </span></label> </div> <div class="firstIndent"> <p class="outputTextNB"> <label id="svapdxI7_1:lblfnaCoPayOthDscr" for="svapdxI7_1:fnaCoPayOthDscr" class="outputLabel"> <span id="svapdxI7_1:lbltxtfnaCoPayOthDscr" class="outputTextNB em">Specify:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxI7_1:fnaCoPayOthDscrChrCntLbl" for="svapdxI7_1:fnaCoPayOthDscrChrCnt" class="outputLabel"> <span id="svapdxI7_1:fnaCoPayOthDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxI7_1:fnaCoPayOthDscrChrCnt" type="text" name="svapdxI7_1:fnaCoPayOthDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxI7_1:fnaCoPayOthDscrChrCntMax" class="chrCnt"> out of 6000</span> </div> <div class="inputTextareaWA"> <span id="svapdxI7_1:panel_fnaCoPayOthDscr"><textarea id="svapdxI7_1:fnaCoPayOthDscr" name="svapdxI7_1:fnaCoPayOthDscr" class="inputTextarea" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> </LI> </OL> </div> <div class="noShow"> <label><input id="svapdxI7_1:fnaCoPayReq:2" type="radio" name="svapdxI7_1:fnaCoPayReq" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label> </div> </LI> </OL> <H2 id="pageTitle">Appendix I: Financial Accountability</H2> <H3 id="pageSubTitle">I-7: Participant Co-Payments for Waiver Services and Other Cost Sharing <SPAN id="pageNumber">(2 of 5)</SPAN></H3> <OL class="alphaLC" start="1"> <LI> <p class="outputTextNB"><strong>Co-Payment Requirements.</strong></p> <OL class="romanLC" start="2"> <LI> <p class="outputTextNB"> <STRONG>Participants Subject to Co-pay Charges for Waiver Services.</STRONG> </p> <p class="underline pph"> <span id="svapdxI7_2:txt_apdxI71_no" class="pph outputText">Answers provided in Appendix I-7-a indicate that you do not need to complete this section.</span> </p> </LI> </OL> </LI> </OL> <H2 id="pageTitle">Appendix I: Financial Accountability</H2> <H3 id="pageSubTitle">I-7: Participant Co-Payments for Waiver Services and Other Cost Sharing <SPAN id="pageNumber">(3 of 5)</SPAN></H3> <OL class="alphaLC" start="1"> <LI> <P class="outputTextNB"><STRONG>Co-Payment Requirements.</STRONG></P> <OL class="romanLC" start="3"> <LI> <P class="outputTextNB"><STRONG>Amount of Co-Pay Charges for Waiver Services.</STRONG></P> <p class="underline pph"> <span id="svapdxI7_3:txt_apdxI71_no" class="pph outputText">Answers provided in Appendix I-7-a indicate that you do not need to complete this section.</span> </p> </LI> </OL> </LI> </OL> <H2 id="pageTitle">Appendix I: Financial Accountability</H2> <H3 id="pageSubTitle">I-7: Participant Co-Payments for Waiver Services and Other Cost Sharing <SPAN id="pageNumber">(4 of 5)</SPAN></H3> <OL class="alphaLC" start="1"> <LI> <p class="outputTextNB"><strong>Co-Payment Requirements.</strong></p> <OL class="romanLC" start="4"> <LI> <p class="outputTextNB"><strong>Cumulative Maximum Charges.</strong> </p> <p class="underline pph"> <span id="svapdxI7_4:txt_apdxI71_no" class="outputText">Answers provided in Appendix I-7-a indicate that you do not need to complete this section.</span> </p> </LI> </OL> </LI> </OL> <H2 id="pageTitle">Appendix I: Financial Accountability</H2> <H3 id="pageSubTitle">I-7: Participant Co-Payments for Waiver Services and Other Cost Sharing <SPAN id="pageNumber">(5 of 5)</SPAN></H3> <OL class="alphaLC" start="2"> <LI> <p class="outputTextNB"> <strong>Other State Requirement for Cost Sharing.</strong> Specify whether the State imposes a premium, enrollment fee or similar cost sharing on waiver participants. <em>Select one</em>: </p> <table id="svapdxI7_5:fnaCoPayOthReq" class="selectOneRadio"> <tr> <td> <input type="radio" checked="checked" name="svapdxI7_5:fnaCoPayOthReq" id="svapdxI7_5:fnaCoPayOthReq:0" value="0" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxI7_5:fnaCoPayOthReq:0"> No. The State does not impose a premium, enrollment fee, or similar cost-sharing arrangement on waiver participants.</label></td> </tr> <tr> <td> <input type="radio" name="svapdxI7_5:fnaCoPayOthReq" id="svapdxI7_5:fnaCoPayOthReq:1" value="1" onclick="return callSave(this, event);" disabled="disabled" /><label for="svapdxI7_5:fnaCoPayOthReq:1"> Yes. The State imposes a premium, enrollment fee or similar cost-sharing arrangement.</label></td> </tr> </table> <div class="firstIndent"> <p class="outputTextNB"> <label id="svapdxI7_5:lblfnaCoPayOthReqDscr" for="svapdxI7_5:fnaCoPayOthReqDscr" class="outputLabel"> <span id="svapdxI7_5:lbltxtfnaCoPayOthReqDscr" class="outputTextNB">Describe in detail the cost sharing arrangement, including: (a) the type of cost sharing (e.g., premium, enrollment fee); (b) the amount of charge and how the amount of the charge is related to total gross family income; (c) the groups of participants subject to cost-sharing and the groups who are excluded; and, (d) the mechanisms for the collection of cost-sharing and reporting the amount collected on the CMS 64:</span></label> </p> <p></p> <div class="chrCntDiv"> <label id="svapdxI7_5:fnaCoPayOthReqDscrChrCntLbl" for="svapdxI7_5:fnaCoPayOthReqDscrChrCnt" class="outputLabel"> <span id="svapdxI7_5:fnaCoPayOthReqDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxI7_5:fnaCoPayOthReqDscrChrCnt" type="text" name="svapdxI7_5:fnaCoPayOthReqDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxI7_5:fnaCoPayOthReqDscrChrCntMax" class="chrCnt"> out of 12000</span> </div> <div class="inputTextareaWA"> <span id="svapdxI7_5:panel_fnaCoPayOthReqDscr"><textarea id="svapdxI7_5:fnaCoPayOthReqDscr" name="svapdxI7_5:fnaCoPayOthReqDscr" class="inputTextareaLong" onkeyup="Count(this);" readonly="readonly"></textarea></span> </div> </div> </LI> </OL> <H2 id="pageTitle">Appendix J: Cost Neutrality Demonstration</H2> <H3 id="pageSubTitle">J-1: Composite Overview and Demonstration of Cost-Neutrality Formula <SPAN id="pageNumber"></SPAN></H3> <div class="firstIndent" id="div4Main"> <div class="outputTextNB" id="div4locTable"> <strong>Composite Overview.</strong> <label id="svapdxJ1_1:lblFor_locTable" for="svapdxJ1_1:jspPanelForLocTable"> <span id="svapdxJ1_1:lbl_txt_locTable" class="outputTextNB">Complete the fields in Cols. 3, 5 and 6 in the following table for each waiver year. The fields in Cols. 4, 7 and 8 are auto-calculated based on entries in Cols 3, 5, and 6. The fields in Col. 2 are auto-calculated using the Factor D data from the J-2-d Estimate of Factor D tables. Col. 2 fields will be populated ONLY when the Estimate of Factor D tables in J-2-d have been completed.</span></label> </div> <p class="outputText"> <label id="svapdxJ1_1:lblFor_combinedLOC" for="svapdxJ1_1:combinedLOC"> <span id="svapdxJ1_1:lbl_txt_combinedLOC" class="outputText">Level(s) of Care: </span></label><span id="svapdxJ1_1:combinedLOC" class="inputText">Nursing Facility</span> </p> <TABLE border="1" cellpadding="0" class="locTable" cellspacing="0" id="locTable"> <THEAD> <TR> <TH id="c1a">Col. 1</TH> <TH id="c2a">Col. 2</TH> <TH id="c3a">Col. 3</TH> <TH id="c4a">Col. 4</TH> <TH id="c5a">Col. 5</TH> <TH id="c6a">Col. 6</TH> <TH id="c7a">Col. 7</TH> <TH id="c8a">Col. 8</TH> </TR> <TR> <TH id="c1b">Year</TH> <TH id="c2b">Factor D</TH> <TH id="c3b">Factor D'</TH> <TH id="c4b">Total: D+D'</TH> <TH id="c5b">Factor G</TH> <TH id="c6b">Factor G'</TH> <TH id="c7b">Total: G+G'</TH> <TH id="c8b">Difference (Col 7 less Column4)</TH> </TR> </THEAD> <TBODY align="right"> <TR> <TD headers="c1a c1b" align="center">1</TD> <TD headers="c2a c2b"> <span id="svapdxJ1_1:cndDYr1" class="inputNum">1928.77</span> </TD> <TD headers="c3a c3b" > <input id="svapdxJ1_1:cndDpYr1" type="text" name="svapdxJ1_1:cndDpYr1" value="43832.00" class="inputNum" size="10" readonly="readonly" /> </TD> <TD headers="c4a c4b"> <span id="svapdxJ1_1:cndDDpYr1" class="inputNum">45760.77</span></TD> <TD headers="c5a c5b"> <input id="svapdxJ1_1:cndGYr1" type="text" name="svapdxJ1_1:cndGYr1" value="49997.13" class="inputNum" size="10" readonly="readonly" /> </TD> <TD headers="c6a c6b"> <input id="svapdxJ1_1:cndGpYr1" type="text" name="svapdxJ1_1:cndGpYr1" value="4391.41" class="inputNum" size="10" readonly="readonly" /> </TD> <TD headers="c7a c7b"> <span id="svapdxJ1_1:cndGGpYr1" class="inputNum">54388.54</span></TD> <TD headers="c8a c8b"> <span id="svapdxJ1_1:cndGsubDYr1" class="inputNum">8627.77</span></TD> </TR> <TR> <TD headers="c1a c1b" align="center">2</TD> <TD headers="c2a c2b"> <span id="svapdxJ1_1:cndDYr2" class="inputNum">3167.14</span> </TD> <TD headers="c3a c3b"> <input id="svapdxJ1_1:cndDpYr2" type="text" name="svapdxJ1_1:cndDpYr2" value="45864.00" class="inputNum" size="10" readonly="readonly" /> </TD> <TD headers="c4a c4b"> <span id="svapdxJ1_1:cndDDpYr2" class="inputNum">49031.14</span></TD> <TD headers="c5a c5b"> <input id="svapdxJ1_1:cndGYr2" type="text" name="svapdxJ1_1:cndGYr2" value="51247.05" class="inputNum" size="10" readonly="readonly" /> </TD> <TD headers="c6a c6b"> <input id="svapdxJ1_1:cndGpYr2" type="text" name="svapdxJ1_1:cndGpYr2" value="4540.71" class="inputNum" size="10" readonly="readonly" /> </TD> <TD headers="c7a c7b"> <span id="svapdxJ1_1:cndGGpYr2" class="inputNum">55787.76</span></TD> <TD headers="c8a c8b"> <span id="svapdxJ1_1:cndGsubDYr2" class="inputNum">6756.62</span></TD> </TR> <TR> <TD headers="c1a c1b" align="center">3</TD> <TD headers="c2a c2b"> <span id="svapdxJ1_1:cndDYr3" class="inputNum">3261.88</span> </TD> <TD headers="c3a c3b"> <input id="svapdxJ1_1:cndDpYr3" type="text" name="svapdxJ1_1:cndDpYr3" value="47799.00" class="inputNum" size="10" readonly="readonly" /> </TD> <TD headers="c4a c4b"> <span id="svapdxJ1_1:cndDDpYr3" class="inputNum">51060.88</span></TD> <TD headers="c5a c5b"> <input id="svapdxJ1_1:cndGYr3" type="text" name="svapdxJ1_1:cndGYr3" value="52528.23" class="inputNum" size="10" readonly="readonly" /> </TD> <TD headers="c6a c6b"> <input id="svapdxJ1_1:cndGpYr3" type="text" name="svapdxJ1_1:cndGpYr3" value="4695.10" class="inputNum" size="10" readonly="readonly" /> </TD> <TD headers="c7a c7b"> <span id="svapdxJ1_1:cndGGpYr3" class="inputNum">57223.33</span></TD> <TD headers="c8a c8b"> <span id="svapdxJ1_1:cndGsubDYr3" class="inputNum">6162.45</span></TD> </TR> <TR> <TD headers="c1a c1b" align="center">4</TD> <TD headers="c2a c2b"> <span id="svapdxJ1_1:cndDYr4" class="inputNum">3315.57</span> </TD> <TD headers="c3a c3b"> <input id="svapdxJ1_1:cndDpYr4" type="text" name="svapdxJ1_1:cndDpYr4" value="49919.00" class="inputNum" size="10" readonly="readonly" /> </TD> <TD headers="c4a c4b"> <span id="svapdxJ1_1:cndDDpYr4" class="inputNum">53234.57</span></TD> <TD headers="c5a c5b"> <input id="svapdxJ1_1:cndGYr4" type="text" name="svapdxJ1_1:cndGYr4" value="53841.44" class="inputNum" size="10" readonly="readonly" /> </TD> <TD headers="c6a c6b"> <input id="svapdxJ1_1:cndGpYr4" type="text" name="svapdxJ1_1:cndGpYr4" value="4854.73" class="inputNum" size="10" readonly="readonly" /> </TD> <TD headers="c7a c7b"> <span id="svapdxJ1_1:cndGGpYr4" class="inputNum">58696.17</span></TD> <TD headers="c8a c8b"> <span id="svapdxJ1_1:cndGsubDYr4" class="inputNum">5461.60</span></TD> </TR> <TR> <TD headers="c1a c1b" align="center">5</TD> <TD headers="c2a c2b"> <span id="svapdxJ1_1:cndDYr5" class="inputNum">3481.80</span> </TD> <TD headers="c3a c3b"> <input id="svapdxJ1_1:cndDpYr5" type="text" name="svapdxJ1_1:cndDpYr5" value="52133.00" class="inputNum" size="10" readonly="readonly" /> </TD> <TD headers="c4a c4b"> <span id="svapdxJ1_1:cndDDpYr5" class="inputNum">55614.80</span></TD> <TD headers="c5a c5b"> <input id="svapdxJ1_1:cndGYr5" type="text" name="svapdxJ1_1:cndGYr5" value="55187.47" class="inputNum" size="10" readonly="readonly" /> </TD> <TD headers="c6a c6b"> <input id="svapdxJ1_1:cndGpYr5" type="text" name="svapdxJ1_1:cndGpYr5" value="5019.79" class="inputNum" size="10" readonly="readonly" /> </TD> <TD headers="c7a c7b"> <span id="svapdxJ1_1:cndGGpYr5" class="inputNum">60207.26</span> </TD> <TD headers="c8a c8b"> <span id="svapdxJ1_1:cndGsubDYr5" class="inputNum">4592.46</span> </TD> </TR> </TBODY> </TABLE> </div> <H2 id="pageTitle">Appendix J: Cost Neutrality Demonstration</H2> <H3 id="pageSubTitle">J-2: Derivation of Estimates <SPAN id="pageNumber">(1 of <span id="svapdxJ2_1:totPages">9</span>)</SPAN></H3> <OL class="alphaLC" start="1"> <LI> <P class="outputTextNB"> <STRONG>Number Of Unduplicated Participants Served.</STRONG> <span id="svapdxJ2_1:lblTxt_table1" class="outputTextNB">Enter the total number of unduplicated participants from Item B-3-a who will be served each year that the waiver is in operation. When the waiver serves individuals under more than one level of care, specify the number of unduplicated participants for each level of care:</span> </P> <TABLE border="1" cellpadding="0" cellspacing="0" id="table1" class="b1Table"> <CAPTION>Table: J-2-a: Unduplicated Participants</CAPTION> <THEAD> <TR> <TH id="yr" rowspan="4">Waiver Year</TH> <TH id="unp" rowspan="4">Total Unduplicated Number of Participants (from Item B-3-a)</TH> <TH id="locunp" colspan="4">Distribution of Unduplicated Participants by Level of Care (if applicable)</TH> </TR> <TR> <TH id="loc2">Level of Care:</TH> </TR> <TR> <TH id="locName2"><span id="svapdxJ2_1:locNurFacLbl">Nursing Facility</span></TH> </TR> </THEAD> <TBODY align="right"> <TR> <TD headers="yr" align="center">Year 1</TD> <TD headers="unp"> <span id="svapdxJ2_1:elgQtyYr1" class="inputNum">1098</span> </TD> <td headers="loc2" class="ctr"> <input id="svapdxJ2_1:cndNurFacYr1" type="text" name="svapdxJ2_1:cndNurFacYr1" value="1098" class="inputNum" readonly="readonly" /> </td> </TR> <TR> <TD headers="yr" align="center">Year 2</TD> <TD headers="unp"> <span id="svapdxJ2_1:elgQtyYr2" class="inputNum">1183</span> </TD> <td headers="loc2" class="ctr"> <input id="svapdxJ2_1:cndNurFacYr2" type="text" name="svapdxJ2_1:cndNurFacYr2" value="1183" class="inputNum" readonly="readonly" /> </td> </TR> <TR> <TD headers="yr" align="center">Year 3</TD> <TD headers="unp"> <span id="svapdxJ2_1:elgQtyYr3" class="inputNum">1270</span> </TD> <td headers="loc2" class="ctr"> <input id="svapdxJ2_1:cndNurFacYr3" type="text" name="svapdxJ2_1:cndNurFacYr3" value="1270" class="inputNum" readonly="readonly" /> </td> </TR> <TR> <TD headers="yr" align="center">Year 4</TD> <TD headers="unp"> <span id="svapdxJ2_1:elgQtyYr4" class="inputNum">1364</span> </TD> <td headers="loc2" class="ctr"> <input id="svapdxJ2_1:cndNurFacYr4" type="text" name="svapdxJ2_1:cndNurFacYr4" value="1364" class="inputNum" readonly="readonly" /> </td> </TR> <TR> <TD headers="yr" align="center">Year 5</TD> <TD headers="unp"> <span id="svapdxJ2_1:elgQtyYr5" class="inputNum">1462</span> </TD> <td headers="loc2" class="ctr"> <input id="svapdxJ2_1:cndNurFacYr5" type="text" name="svapdxJ2_1:cndNurFacYr5" value="1462" class="inputNum" readonly="readonly" /> </td> </TR> </TBODY> </TABLE> </LI> </OL> <H2 id="pageTitle">Appendix J: Cost Neutrality Demonstration</H2> <H3 id="pageSubTitle">J-2: Derivation of Estimates <SPAN id="pageNumber">(2 of <span id="svapdxJ2_2:totPages">9</span>)</SPAN></H3> <OL class="alphaLC" start="2"> <LI><P class="outputTextNB"><STRONG>Average Length of Stay.</STRONG> <LABEL for="textarea1">Describe the basis of the estimate of the average length of stay on the waiver by participants in item J-2-a.</LABEL></P> <div class="chrCntDiv"> <label id="svapdxJ2_2:cndALOSChrCntLbl" for="svapdxJ2_2:cndALOSChrCnt" class="outputLabel"> <span id="svapdxJ2_2:cndALOSChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxJ2_2:cndALOSChrCnt" type="text" name="svapdxJ2_2:cndALOSChrCnt" class="chrCnt" size="6" /><span id="svapdxJ2_2:cndALOSChrCntMax" class="chrCnt"> out of 6000</span> </div> <DIV class="inputTextareaWA"> <span id="svapdxJ2_2:panel_cndALOS"><textarea id="svapdxJ2_2:cndALOS" name="svapdxJ2_2:cndALOS" class="inputTextareaLong" onkeyup="Count(this);" readonly="readonly">The length of stay was calculated by dividing the annual summary of client days by the annual unduplicated caseload (factor c). The client day count was derived by multiplying the total beginning of the month client caseload by the number of days in the month.</textarea></span> </DIV> </LI> </OL> <H2 id="pageTitle">Appendix J: Cost Neutrality Demonstration</H2> <H3 id="pageSubTitle">J-2: Derivation of Estimates <SPAN id="pageNumber">(3 of <span id="svapdxJ2_3:totPages">9</span>)</SPAN></H3> <OL class="alphaLC" start="3"> <LI><P class="outputTextNB"><STRONG>Derivation of Estimates for Each Factor.</STRONG> Provide a narrative description for the derivation of the estimates of the following factors.</P> <OL class="romanLC" start="1"> <LI> <label id="svapdxJ2_3:lblFor_cndDoeD" for="svapdxJ2_3:cndDoeD" class="outputLabelNB"> <span id="svapdxJ2_3:lblTxt1_cndDoeD" class="outputText">Factor D Derivation. </span><span id="svapdxJ2_3:lblTxt2_cndDoeD" class="outputTextNB">The estimates of Factor D for each waiver year are located in Item J-2-d. The basis for these estimates is as follows:</span></label> <p></p> <div class="chrCntDiv"> <label id="svapdxJ2_3:cndDoeDChrCntLbl" for="svapdxJ2_3:cndDoeDChrCnt" class="outputLabel"> <span id="svapdxJ2_3:cndDoeDChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxJ2_3:cndDoeDChrCnt" type="text" name="svapdxJ2_3:cndDoeDChrCnt" class="chrCnt" size="6" /><span id="svapdxJ2_3:cndDoeDChrCntMax" class="chrCnt"> out of 12000</span> </div> <DIV class="inputTextareaWA"> <span id="svapdxJ2_3:panel_cndDoeD"><textarea id="svapdxJ2_3:cndDoeD" name="svapdxJ2_3:cndDoeD" class="inputTextarea" onkeyup="Count(this);" readonly="readonly">The estimates of factor D are based on past utilization of services and prorated for estimates of increased enrollment, the addition of Care Management and the removal of Personal Care Assistance, Personal Emergency Response System, Assistive Technology.</textarea></span> </DIV> </LI> <LI> <label id="svapdxJ2_3:lblFor_cndDoeDp" for="svapdxJ2_3:cndDoeDp" class="outputLabelNB"> <span id="svapdxJ2_3:lblTxt1_cndDoeDp" class="outputText">Factor D' Derivation. </span><span id="svapdxJ2_3:lblTxt2_cndDoeDp" class="outputTextNB">The estimates of Factor D' for each waiver year are included in Item J-1. The basis of these estimates is as follows:</span></label> <p></p> <div class="chrCntDiv"> <label id="svapdxJ2_3:cndDoeDpChrCntLbl" for="svapdxJ2_3:cndDoeDpChrCnt" class="outputLabel"> <span id="svapdxJ2_3:cndDoeDpChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxJ2_3:cndDoeDpChrCnt" type="text" name="svapdxJ2_3:cndDoeDpChrCnt" class="chrCnt" size="6" /><span id="svapdxJ2_3:cndDoeDpChrCntMax" class="chrCnt"> out of 12000</span> </div> <DIV class="inputTextareaWA"> <span id="svapdxJ2_3:panel_cndDoeDp"><textarea id="svapdxJ2_3:cndDoeDp" name="svapdxJ2_3:cndDoeDp" class="inputTextarea" onkeyup="Count(this);" readonly="readonly">Factor D' was based on the previous "initial" W-372 report for the PCA waiver. The historic cost data were trended forward using actual CPI trends for medical care. The submitted application did not contain the cost of prescribed drugs for dual eligible Medicare/Medicaid clients. Factor D'was based on 372 reports that exclude dual eligible clients pharmacy expenditures;therefore, Factor D' did not require additional adjustment.Factor D&#8217; was increased for the addition of Personal Care Assistance, Personal Emergency Response, and Assistive Technology to the state plan as of 7/1/15. Historic cost data from the 372 reports were trended forward using actual CPA trends for medical care.</textarea></span> </DIV> </LI> <LI> <label id="svapdxJ2_3:lblFor_cndDoeG" for="svapdxJ2_3:cndDoeG" class="outputLabelNB"> <span id="svapdxJ2_3:lblTxt1_cndDoeG" class="outputText">Factor G Derivation. </span><span id="svapdxJ2_3:lblTxt2_cndDoeG" class="outputTextNB">The estimates of Factor G for each waiver year are included in Item J-1. The basis of these estimates is as follows:</span></label> <p></p> <div class="chrCntDiv"> <label id="svapdxJ2_3:cndDoeGChrCntLbl" for="svapdxJ2_3:cndDoeGChrCnt" class="outputLabel"> <span id="svapdxJ2_3:cndDoeGChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxJ2_3:cndDoeGChrCnt" type="text" name="svapdxJ2_3:cndDoeGChrCnt" class="chrCnt" size="6" /><span id="svapdxJ2_3:cndDoeGChrCntMax" class="chrCnt"> out of 12000</span> </div> <DIV class="inputTextareaWA"> <span id="svapdxJ2_3:panel_cndDoeG"><textarea id="svapdxJ2_3:cndDoeG" name="svapdxJ2_3:cndDoeG" class="inputTextarea" onkeyup="Count(this);" readonly="readonly">Factor G was based on the W-372 report for the third year of the PCA waiver. The historic cost data were trended forward using actual CPI trends for medical care.</textarea></span> </DIV> </LI> <LI> <label id="svapdxJ2_3:lblFor_cndDoeGp" for="svapdxJ2_3:cndDoeGp" class="outputLabelNB"> <span id="svapdxJ2_3:lblTxt1_cndDoeGp" class="outputText">Factor G' Derivation. </span><span id="svapdxJ2_3:lblTxt2_cndDoeGp" class="outputTextNB">The estimates of Factor G' for each waiver year are included in Item J-1. The basis of these estimates is as follows:</span></label> <p></p> <div class="chrCntDiv"> <label id="svapdxJ2_3:cndDoeGpChrCntLbl" for="svapdxJ2_3:cndDoeGpChrCnt" class="outputLabel"> <span id="svapdxJ2_3:cndDoeGpChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxJ2_3:cndDoeGpChrCnt" type="text" name="svapdxJ2_3:cndDoeGpChrCnt" class="chrCnt" size="6" /><span id="svapdxJ2_3:cndDoeGpChrCntMax" class="chrCnt"> out of 12000</span> </div> <DIV class="inputTextareaWA"> <span id="svapdxJ2_3:panel_cndDoeGp"><textarea id="svapdxJ2_3:cndDoeGp" name="svapdxJ2_3:cndDoeGp" class="inputTextarea" onkeyup="Count(this);" readonly="readonly">Factor g' was based on the W-372 report for the third year of the PCA waiver. The historic cost data were trended forward using actual CPI trends for medical care.</textarea></span> </DIV> </LI> </OL> </LI> </OL> <H2 id="pageTitle">Appendix J: Cost Neutrality Demonstration</H2> <H3 id="pageSubTitle">J-2: Derivation of Estimates <SPAN id="pageNumber">(4 of <span id="svapdxJ2_3a:totPages">9</span>)</SPAN></H3> <p> <span id="svapdxJ2_3a:nonConc" class="outputText">Component management for waiver services. </span> <span class="outputTextNB" > If the service(s) below includes two or more discrete services that are reimbursed separately, or is a bundled service, each component of the service must be listed. Select &ldquo;<em>manage components</em>&rdquo; to add these components. </span> </p> <table id="svapdxJ2_3a:services" title="Services" class="dtServices" border="1" cellpadding="2" cellspacing="0" summary="Table of waiver services" ><thead ><tr ><th scope="col" ><span id="svapdxJ2_3a:services:colServiceType" class="outputText" style="width: 75%;">Waiver Services</span></th><th scope="col" ><img src="/WMS/.ibmjsfres/img/1x1.gif" ></img></th></tr> </thead><tbody > <tr ><td class="columnClass6" ><span id="svapdxJ2_3a:services:0:serviceName" class="outputText">Care Management</span></td> <td class="columnClass5" ></td> </tr> <tr ><td class="columnClass6" ><span id="svapdxJ2_3a:services:1:serviceName" class="outputText">Independent Support Broker</span></td> <td class="columnClass5" ></td> </tr> <tr ><td class="columnClass6" ><span id="svapdxJ2_3a:services:2:serviceName" class="outputText">Adult Family Living/Foster Care</span></td> <td class="columnClass5" ></td> </tr> </tbody> </table> <H2 id="pageTitle">Appendix J: Cost Neutrality Demonstration</H2> <H3 id="pageSubTitle">J-2: Derivation of Estimates <SPAN id="pageNumber">(5 of <span id="svapdxJ2_4:totPages">9</span>)</SPAN></H3> <OL class="alphaLC" start="4"> <LI><P class="outputTextNB"><STRONG>Estimate of Factor D.</STRONG> </P> <p> <span id="svapdxJ2_4:Conc" class="outputText">ii. Concurrent &sect;1915(b)/&sect;1915(c) Waivers, or other authorities utilizing capitated arrangements (i.e., 1915(a), 1932(a), Section 1937).</span><label id="svapdxJ2_4:lbl_conc_dtEstFctrD" for="svapdxJ2_4:dtEstFctrD"> <span id="svapdxJ2_4:lblTxt_conc_dtEstFctrD" class="outputTextNB">Complete the following table for each waiver year. Enter data into the Unit, # Users, Avg. Units Per User, and Avg. Cost/Unit fields for all the Waiver Service/Component items. If applicable, check the capitation box next to that service. Select Save and Calculate to automatically calculate and populate the Component Costs and Total Costs fields. All fields in this table must be completed in order to populate the Factor D fields in the J-1 Composite Overview table.</span></label> </p> </LI> </OL> <p class="outputText tableTitle"> <label id="svapdxJ2_4:lbl_dtEstFctrD2" for="svapdxJ2_4:dtEstFctrD"> <span id="svapdxJ2_4:lblTxt_dtEstFctrD2">Waiver Year: Year 1</span></label> </p> <table id="svapdxJ2_4:dtEstFctrD" class="estFD" dir="ltr" border="1" cellpadding="2" cellspacing="0" summary="Table of waiver services Factor D estimates" ><thead ><tr ><th class="ctr" scope="col" ><span id="svapdxJ2_4:dtEstFctrD:txt_serviceCol" class="outputText">Waiver Service/ Component</span></th><th class="ctr" scope="col" ><span id="svapdxJ2_4:dtEstFctrD:txt_inCapCol" class="outputText">Capi-tation</span></th><th class="ctr" scope="col" ><span id="svapdxJ2_4:dtEstFctrD:txt_cndEstDUnitsCol" class="outputText">Unit</span></th><th class="ctr" scope="col" ><span id="svapdxJ2_4:dtEstFctrD:txt_cndEstDUsersCol" class="outputText"># Users</span></th><th class="ctr" scope="col" ><span id="svapdxJ2_4:dtEstFctrD:txt_cndEstDUnitsPerUsercol" class="outputText">Avg. Units Per User</span></th><th class="ctr" scope="col" ><span id="svapdxJ2_4:dtEstFctrD:txt_cndEstDCostPerUnitCol" class="outputText">Avg. Cost/ Unit</span></th><th class="ctr" scope="col" ><span id="svapdxJ2_4:dtEstFctrD:txt_cmptTotalCostCol">Component Cost</span></th><th class="ctr" scope="col" ><span id="svapdxJ2_4:dtEstFctrD:txt_svcTotCostCol">Total Cost</span></th></tr> </thead><tbody > <tr ><td class="columnClass11" ><span id="svapdxJ2_4:dtEstFctrD:0:serviceName" class="outputText">Care Management</span><span id="svapdxJ2_4:dtEstFctrD:0:serviceName2" class="outputText"> Total:</span></td> <td class="columnClass13" ><span id="svapdxJ2_4:dtEstFctrD:0:phcndEstDInCap" class="outputText"> </span></td> <td class="columnClass14" > <p></p> <span id="svapdxJ2_4:dtEstFctrD:0:ph_cndEstDUnitsCol" class="outputText"> </span></td> <td class="columnClass15" > <p></p> <span id="svapdxJ2_4:dtEstFctrD:0:ph_cndEstDUsersCol" class="outputText"> </span></td> <td class="columnClass16" > <p></p> <span id="svapdxJ2_4:dtEstFctrD:0:ph_cndEstDUnitsPerUsercol" class="outputText"> </span></td> <td class="columnClass17" > <p></p> <span id="svapdxJ2_4:dtEstFctrD:0:ph_cndEstDCostPerUnitCol" class="outputText"> </span></td> <td class="columnClass18" ><span id="svapdxJ2_4:dtEstFctrD:0:ph_cmptTotalCostCol" class="outputText"> </span></td> <td class="columnClass19" ><span id="svapdxJ2_4:dtEstFctrD:0:totalCost" class="inputNum">421532.10</span></td> </tr> <tr ><td class="columnClass11" ><span id="svapdxJ2_4:dtEstFctrD:1:serviceNameCmpt" class="outputTextNB indent">Tier A Care Management</span></td> <td class="columnClass13" ><input id="svapdxJ2_4:dtEstFctrD:1:cndEstDInCap" type="checkbox" name="svapdxJ2_4:dtEstFctrD:1:cndEstDInCap" class="selectBooleanCheckbox" disabled="disabled" /></td> <td class="columnClass14" > <p></p> <input id="svapdxJ2_4:dtEstFctrD:1:cndEstDUnits" type="text" name="svapdxJ2_4:dtEstFctrD:1:cndEstDUnits" value="per day" class="inputTextOth columnClass12" maxlength="30" size="15" readonly="readonly" /></td> <td class="columnClass15" > <p></p> <input id="svapdxJ2_4:dtEstFctrD:1:cndEstDUsers" type="text" name="svapdxJ2_4:dtEstFctrD:1:cndEstDUsers" value="548" class="inputNum" maxlength="9" size="8" style="" readonly="readonly" /></td> <td class="columnClass16" > <p></p> <input id="svapdxJ2_4:dtEstFctrD:1:cndEstDUnitsPerUser" type="text" name="svapdxJ2_4:dtEstFctrD:1:cndEstDUnitsPerUser" value="83.00" class="inputNum" maxlength="8" size="10" readonly="readonly" /></td> <td class="columnClass17" > <p></p> <input id="svapdxJ2_4:dtEstFctrD:1:cndEstDCostPerUnit" type="text" name="svapdxJ2_4:dtEstFctrD:1:cndEstDCostPerUnit" value="4.40" class="inputNum" maxlength="8" size="10" readonly="readonly" /></td> <td class="columnClass18" ><span id="svapdxJ2_4:dtEstFctrD:1:totalCostComponent" class="inputNum">200129.60</span></td> <td class="columnClass19" ><span id="svapdxJ2_4:dtEstFctrD:1:ph_svcTotCostCol" class="outputText"> </span></td> </tr> <tr ><td class="columnClass11" ><span id="svapdxJ2_4:dtEstFctrD:2:serviceNameCmpt" class="outputTextNB indent">Tier B Care Management</span></td> <td cla