ÿþ<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN" "http://www.w3.org/TR/html4/loose.dtd"> <HTML lang="us-en"> <HEAD> <META http-equiv="Content-Type" content="text/html; charset=UTF-8"> <STYLE type="text/css" media="screen,print"> <!-- body,html { margin:0; padding:0; font-family: "Times New Roman", serif; font-size: 10pt; height: 100%; } #container { width: 100%; } #header { font-weight: bold; font-size: 2em; margin-bottom: .75em; } #header #headerText { color: #737373; background-color: transparent; margin: 0; text-align: left; border-bottom-width: thick; border-bottom-style: solid; border-bottom-color: #737373; } #headerLinks { display: none; } .printHeader { background-color:gray; color: white; font-weight: bold; font-size: 1.5em; text-align: center; } a#skipLinks { /*display: none;*/ position:absolute; left:-10000px; top:auto; width:1px; height:1px; overflow:hidden; } a:focus#skipLinks { position:static; width:auto; height:auto; } .hidden { position:absolute; left:-10000px; top:auto; width:1px; height:1px; overflow:hidden; } #leftMenu { display: none; } #content { margin: 0 1em; /*width: auto;*/ padding: 0; } #navContBack { display: none; } #navContBackBtm { display: none; } #footer { display: none; } .firstIndent { margin-left: 2em; } .shortEssay { width: 100%; height: 4em; } #sectionTitle{ color: #737373; background-color: transparent; font-size: 1.2em; } #pageTitle { color: #737373; background-color: transparent; font-size: 1.3em; border-bottom-color: #737373; border-bottom-width: medium; border-bottom-style: solid; margin-bottom: .75em; font-weight: bold; } #pageNumber { font-size: .85em; } #pageSubTitle { color: #737373; background-color: transparent; font-size: 1.3em; margin-top: -.75em; margin-left: 4.25em; font-weight: bold; } #pageDesc { color: #737373; background-color: transparent; font-weight: bold; margin-bottom: 1em; } #content p, #repeater p { margin: .25em 0; } #content div.paragraph { margin-bottom: 1em; } #content p.pph { margin: 1em 0; } .ul { text-decoration: underline; } .bld { font-weight: bold; } .noShow { display: none; } .em { font-style: italic; } .smallFont { font-size: .75em; } .tableTitle { margin: 1em 0 0; text-align: center; } #userSecurity { display: none; } .lft { text-align: left; } .rgt { text-align: right; } .ctr { text-align: center; } .delThis { font-size: 1.1em; font-weight: bold; color: black; background-color: transparent; } .indent { margin-left: 1.5em; } /******************************** * Faces Components Stylesheet * ********************************/ .noPrint { display: none; } OL.alpha, OL.alphaLC, OL.numeric, OL.roman, OL.romanLC { color: black; background-color: transparent; font-weight: bold; } OL.alpha { list-style: upper-alpha outside; } OL.alphaLC { list-style: lower-alpha outside; } OL.numeric { list-style-type: decimal; } OL.roman { list-style-type: upper-roman; } OL.romanLC { list-style-type: lower-roman; } OL.numeric.outputTextNB { font-weight: normal; } UL { list-style: square; } .third{ width:30%; text-align: left; vertical-align: top;} .tblCoPayTD { vertical-align: top; text-align: left; font-size: .75em; width: 20%; } .tblCoPayChkTD { vertical-align: top; text-align: center; } TABLE.ckboxTable, TABLE.b1Table, TABLE.locTable, TABLE.tblCoPay, Table.tblFinder, table.errDataTable, table.b3a { font-size: .85em; border-color: black; border-width: 1px; border-style: solid; text-align: center; margin-top: 1em; } table.b3a { width: 95%; } .estFD { font-size: .75em; border-color: black; border-width: 1px; border-style: solid; margin-top: 1em; margin-bottom: 1em; width: 90%; } .width95 { width: 85%; } .width98 { width: 90%; } table.b3aNB{ font-size: .85em; text-align: center; margin: 1em 0; width: 95%; } table.errDataTable { text-align: left; } table.errDataTable TD { padding: 0 .5em; } TABLE.tblFinder TD { text-align: left; padding: 0 .5em; } table.dtServices, table.tblEst { font-size: .85em; border-color: black; border-width: 1px; border-style: solid; margin-top: 1em; text-align: left; margin-left: 2em; /*width: 95%;*/ } table.dtServices th { text-align: center; } table.tblEst td .inputNum, table.tblEst td .inputOth, table.tblEst td .outputNum, table.tblEst td .selectBooleanCheckbox { font-size: .75em; } table.tblEst{ width: 98%; } table.tblEst th { text-align: center; } table.nstTableX { font-size: 10pt; border: 0; text-align: left; width: 95%; } TABLE.tblFinder TH, table.errDataTable TH { padding: 0 .5em; } TABLE.tblFinder TD { text-align: left; padding: 0 .5em; } TABLE.tblFinder TH { padding: 0 .5em; } Table.locTable CAPTION{ text-align: left; } THEAD, CAPTION { font-weight: bold; } TABLE.ckboxTable THEAD { font-weight: bold; } Table.ckboxTable TD.rowHead, TD.desc { text-align: left; } TABLE.b1Table TD { width: 10%; } TABLE.b1Table TD.desc, TD.desc { width: 20%; } table.tblContacts { width: 95%; } .topCol { vertical-align: top; font-size: .85em; color: black; } .headCol { vertical-align: bottom; font-size: .85em; color: black; } .table-header { color: black; } .table-background { border: 2px outset black; border-collapse: collapse; font-family: Arial, sans-serif; font-size: 10pt; text-align: left; width: 100%; } .form { } .rowHL { text-align: left; background-color: silver; font-weight: bold; } .disabled { color: gray; background-color: transparent; } .commandExButton { display: none } .commandButton { display: none } .commandLink { color: #737373; background-color: transparent; } .menuDesc{ margin-top: .5em; margin-right: 10em; margin-bottom: 1em; /*border-bottom: thin gray solid; border-right: thin gray solid;*/ } .outputLinkEx { } .graphicImageEx { } .outputLabel { } .inputText, .inputTextSmall, .inputTextLong, .inputTextPct, .inputText4EM, .inputTextarea30, .inputTextarea25, .inputTextarea15, .inputTextarea5, inputTextarea2, .inputTextarea, .inputTextareaLong, .selectOneMenu, .inputOth, .inputNum, .outputNum, .inputTextOth { font-family: "Times New Roman", serif; } .inputText { width: 40%; } .inputTextSmall { width: 10%; } .inputTextLong { width: 99%; } .inputTextPct { width: 80%; } .inputText4EM { width: 4em; } .inputOth { text-align: left; } .inputNum { text-align: right; } .outputNum { text-align: right; font-weight: bold; } .inputText_Error { border-style: solid; border-color: #DE5C5C; } .inputTextarea, .inputTextarea2, .inputTextarea30, .inputTextarea25, .inputTextarea15, .inputTextarea5{ width: 99%; height: auto; overflow: visible; } .inputTextareaLong { width: 99%; height:auto; overflow: visible; } .inputTextareaWA { margin: 0; padding: 0; width: 99%; height: auto; border: none; font-weight: normal; font-size: 10pt; } fieldset { border: none; margin: 0; padding: 0; } .inputTextareaWA fieldset { margin: 0; padding: 0; width: 100%; } .inputSecret { width: 40%; } .outputText, .outputTextNB, .outputText40{ color: black; background-color: transparent; font-weight: bold; } .outputText40 { width: 40%; } .outputTextNB { font-weight: normal; } .outputTextPrint{ width: 50px; color: #3366cc; background-color: transparent; font-weight: bold; word-wrap: break-word; } .outputFormat { } .outputSeparator { } .message { } .messages { } .qLabel { width: 15%; color: black; background-color: transparent; font-weight: bold; font-size: .90em; } .checkboxGroup { margin: 0; padding-left: 2em; text-indent: -1.75em; /*width: auto;*/ } .selectBooleanCheckbox { vertical-align: top; } .aprvdSec { border-color: #737373; border-width: thin; border-style: solid } .underline { border-bottom: black thin solid; border-top: black thin solid; margin: .5em 0; } .overline { border-top: black thin solid; } .selectOneRadio, .selectOneRadio td { color: black; background-color: transparent; font-weight: bold; font-size: 1em; vertical-align: top; margin-left: 0; padding-left: 2em; text-indent: -1.50em; } .selectOneRadio_Disabled { color: GrayText; background-color: transparent; } div.radioGroup { color: black; background-color: transparent; font-weight: bold; } .selectManyCheckbox { } .selectManyCheckbox_Disabled { color: GrayText; } .selectOneListbox { } .selectManyListbox { } .selectOneMenu { width: 40%; } .panelGrid { } .jspPanel { } /************************************* * Compound Component: Data Grid * *************************************/ .dataTable { } .headerClass { background-color: ThreeDFace; color: WindowText; border-width: 1px; border-style: solid; border-color: ThreeDShadow; margin:2px; padding:0px; padding-left:4pt; padding-right:4pt; padding-bottom:2px; font-weight: 400; } .footerClass { background-color: ThreeDFace; color: WindowText; border-width: 0px; border-style: none; padding:0px; padding-left:4pt; padding-right:4pt; font-weight: 400; } .rowClass1 { background-color: Window; } .rowClass2 { background-color: ThreeDFace; } .columnClass1 { background-color: Window; } .columnClass2 { background-color: ThreeDFace; } .columnClass3 { color: black; background-color: transparent; text-align: center; padding: 1px 3px; } .columnClass3nbr { color: black; background-color: transparent; text-align: right; padding-right: 10px; font-size: 1.05em; } .columnClass4 { color: #3366cc; background-color: transparent; text-align: center; } .columnClass5 { /* columns with buttons */ width: 0%; text-align: center; } .columnClass6 { background-color: Window; width: 85%; } /* Column classes for Estimates * of Factor D. */ .columnClass11 { font-size: 1em; 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.020.06.01 - Apr 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">Home and Community Based Services Waiver for Elders</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.0140</span> </div> <div> <span id="svamend1_1:txtlblOrigWvrBaseNbr_ro" class="outputText">Original Base Waiver Number: CT.0140.</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="04/01/18" 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">07/01/15</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 125% of the average Medicaid cost of nursing home effective 7/1/18 and to 130% 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="B 2-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" 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">Home and Community Based Services Waiver for Elders</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.0140</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.020.06.01</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">07/01/15</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">07/01/15</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">The state is requesting a 1915b(4) concurrent with this submission for selective contracting for the provision of the care management service.</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">The Department of Social Services, as the state Medicaid agency pursuant to CT General Statutes (CGS) 17b-1, operates the Home and Community Based Services Waiver according to CGS 17b-342 for individuals age 65 and over to enable frail elders to be deinstitutionalized or diverted from nursing home placement. The Department's Alternate Care Unit administers the waiver, accepts applications, does the initial level of care determination and refers 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 maintain ongoing contact with the clients and are required to do semi-annual face to face evaluations with the comprehensive evaluation being required annually. The case management organizations are also responsible for loading authorized service plans into the MMIS contractor portal so that enrolled providers can bill directly but only for services authorized as part of the care plan. For PCA services, a fiscal intermediary processes the weekly payroll. The same fiscal intermediary will credential the waiver providers. Providers then enroll directly with the Department. Quality assurance and improvement activities are conducted by both the care management agencies and the Department. The Department has extensive reporting requirements of the case management agencies including quarterly quality assurance summaries. Services provided by the waiver include Case Management, Homemaker, Adult Family Living/Foster Care, Companion, Chore, Adult Day Health,Personal Emergency Response Systems, Personal Care (Agency based), Assistive Technology, Respite, Transportation, Home Delivered Meals, Mental Health Counseling, Personal Care Assistant, and Environmental Accessibility Adaptations. Personal Care Assistant will be available to clients either as a fully self directed model or as agency with choice thus giving the participants more options for care. With this renewal we are intending to add a tiered care management service, Care Transitions and Chronic Disease Self-Management Program (both of which are evidence-based programs), Bill Payer Service, Recovery Assistant and Independent Support Broker. Support Broker may be provided as a self directed or agency based service and will be available after the participant has utilized a $500 benefit under the 1915k state plan option. Additionally we are adding a NF sub-acute level of care to accommodate the increasing care needs of program applicants. We are removing self directed PCA from this waiver as the state will be operating a 1915k state plan option for PCA services. Our intention is to align the removal of the service with the approval date of the CFC application. the transition will be seamless to both the participant and the providers.</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">The state sought public input from multiple sources in preparation of the renewal. A presentation was also made to the Home Care Advisory Committee consisting primarily of the provider network including the CT Home Care Association and the Adult Day Care Association of CT as well as representatives from the legal services community and the Commission on Aging. The Department has solicited input from the two tribal nations in Connecticut. Both tribes were provided with a copy of the Notice of Intent that was published in the CT Law Journal and were provided copies of the waiver application via email. Neither of the tribes responded. In addition to the CT law Journal posting, the Department posted the renewal notice on its web site under Latest News. No comments were received from the postings. Additional posting were made via the DSS web on 4/20/15 and printed in the CT Law Journal on 5/5/15.</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" 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"></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 following language was included in amendment 020.05.04 and was approved by CMS in February of 2015. In preparing for the amendment, the state reviewed the waiver and identified 3 services and one setting that required further review to assure compliance with the new HCBS requirements. The three services are Adult Day Health, Adult Family Living and Assisted Living. The settings requiring review are the Residential Care Homes. Adult Day Health: This is a community based service that brings waiver participants to a center to receive services, meals care and opportunities to participate in activities both within the center and in the greater community. Some centers are located adjacent o or on the grounds of long term care facilities. The certification process requires that there be a separate entrance and separate bathing and bathroom facilities. The service is freely chosen by the participant from a range of services and providers as part of the person centered planning process. In reviewing this service, the state has determined that it is fully compliant with the new CMS regulations but will work on several enhancements to ensure the home based look and feel the is expected under the regulations. As part of the overall transition plan, the department will review its own regulations regarding this service and make modifications and be more explicit about the expectations of community integration and the overall look and feel of the setting itself. In addition, the department has already engaged in conversations with the certification reviewers and there is agreement to make modifications to the certification process to describe expectations of community inclusion and activities as well as a clear description of the expectations of the appearance of a home like environment. As part of the transition plan, the state will include sample of monthly calendars from a range of Day Centers that illustrate activities to promote community inclusion that comply with the new rules. Adult Family Living: This service is provided in either the home of the participant or the caregiver. This service is freely chosen by the participant from a range of services by qualified providers as part of the person centered plan. Assisted Living: The state reviewed the settings in which assisted living services are provided and also met with representatives of the Ct Assisted Living association. Our analysis concluded that the state is in full compliance with the new HCBS settings requirements. Assisted living services are provided in a managed residential community. The community assists residents in integrating into the greater community, is a setting freely selected by the waiver participant, ensures the individuals rights to privacy and dignity and facilitates choice for services available outside of the bundled assisted living service. All persons residing in managed residential communities have a lease with eviction protections, their doors are lockable, they have cooking facilities and access to food at any time, are free to decorate their unit as they choose, can have visitors at any time and the setting is physically accessible. The setting is a private apartment unless a roommate option is selected by the waiver participant. Residential Care Homes: Initially, the department set out to identify the number of waiver participants residing in residential care homes. An analysis indicates there are 254 participants residing in RCHs. These locations in the state vary widely in the appearance, size and home like qualities. The state recognizes that some of the settings will be fully compliant with the new regulations while others will need to make changes to become compliant. To accomplish this, the state has a number of steps it needs to take. First, all case managers were trained on the new rules and were introduced to a survey to be utilized from September 1, 2014 through February 28, 2015 when performing the annual or semi-annual reassessment at the RCH. Each client will be asked about the choice of setting they prefer to live in and will also focus on areas such as privacy, dignity and respect as well as choice of HCBS waiver providers. Case managers will evaluate if the setting was clearly chosen by the participant as part of the person centered plan. A survey will also be developed and distributed to all RCHs in the state to do a self assessment of compliance during the same time period. It is anticipated that a meeting with the association would need to take place either prior to or after the analysis of the survey data. The department will also engage in conversations with the CT Department of Public Health that licenses residential care homes to determine if regulatory changes might be needed to ensure compliance with the HCBS settings rules. This will be accomplished by June 30, 2015. Our goal will be to include language from the new rules to be incorporated into the RCH regulations. A summary of the survey findings will identify areas that changes will need to be made to bring the setting into full compliance. The state will engage with stakeholders to provide input on a final transition plan that will be submitted to CMS for final approval by 10/31/14. Notice was published in the CT Law Journal on 7/8/2014 outlining both the changes resulting in the amendment and the transition plan. In addition, the tribes were notified of the amendment and transition plan on 6/26/14. A second notice soliciting comments was published on the DSS web site on July 22, 2014. The state received comments from Leading Age CT and three of the four contracted Access Agencies who do the care management under this waiver. All commenters were supportive of the plan developed by the department. Leading Age supported the department's conclusion that the Adult Day programs and Assisted Living are compliant with the new rules. They also committed to assisting with the assessment process for the residential care homes. The Access Agencies commented that the survey process of the residential care homes will provide valuable information to assess compliance and variation across the range of settings. One suggestion was to convene regional housing groups to explore housing options in light of the new rules. Overall, there was agreement with the department's conclusion that Adult Day and Assisted Living were compliant with the new rules.</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">The State assures that the settings transition plan included with this waiver renewal 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.&#8221;</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">Home and Community Based Services 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 department contracts with Access Agencies as defined in CGS 17b-342(b). The Access Agency is required to hire appropriate staff to perform case management 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. As part of the case management process, the Access Agency is responsible for evaluating the utilization of the authorized services. 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. The Department's fiscal intermediary credentials the providers who wish to be enrolled as a waiver service provider. They also act as the fiscal agent for the self directed personal care assistants. The direct service waiver providers will directly enroll with the Department's MMIS contractor and bill the HCBS claims directly through a portal developed by the MMIS contractor where the claim is compared to the authorized service plan. This occurs only after the provider has been credentialed by the fiscal intermediary. The contract for the Access Agencies and the fiscal intermediary were both awarded as the result of a competitive procurement.</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 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.</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">The Department oversees performance of contracted entities by conducting comprehensive client record reviews through onsite or desk audit reviews. These reviews monitor access agency compliance with state and federal law in additon to contractual compliance. The department reviews 100% of assessment outcomes on new client admissions to the program to verify level of care and authorize the service plan. The Department manages the waiver expenditures against the approved levels by utilizing paid claims data reports from our data warehouse. Our ability to do this has been enhanced by the creation of the MMIS portal through which all service authorizations and claims flow. Both department HCBS staff and Access Agency staff assume responsibility for utilization management functions. All new Total Plans of Care and a sample of reassessment Total Plans of Care are reviewed by Alternate Care staff nurses. Additionally, Alternate Care staff conduct record audits of the Access Agencies client records and the appropriateness of the Total Plan of Care is compared to the identified needs. Access Agency supervisors do ongoing utilization review as they review clinical records. The Department has a formal reporting process for the Access Agencies to report the data captured in the supervisory record reviews. As new providers are seeking enrollment as a waiver provider, the fiscal intermediary reviews the application and determines if the provider meets the qualifications to be a waiver provider. They then facilitate the application through the Department's provider enrollment process. The final decision on enrollment is made by the Department's Quality assurance staff who ensure that all qualifications are met. The Access Agencies and fiscal intermediary are also contractually obligated to provide reports to the Department either monthly, quarterly, semiannually or annually. Quality assurance reports to the Department from the Access Agencies are reviewed by Department staff for trends and the possible need for remediation. Receipt of the reports is tracked by HCBS staff. Appropriate remedial actions are taken if needed.</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="223105" 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" 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="223253" 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="223145" 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="223125" 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="223205" 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="223091" 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" 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="223177" 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="223086" 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="223133" 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" 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="223135" 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="223190" 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="223087" 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 Access Agencies that receive both a clinical and administrative review by Department staff in an eighteen month period. Numerator is number of Access Agencies that receive a review within 18 months and the denominator is the total number of Access Agencies</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" checked="checked" 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" 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" checked="checked" 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">contracted entity</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" 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" checked="checked" 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" readonly="readonly">every 18 months</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> <tr ><td ><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsTypeLbl" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsType"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsTypeDDDiv"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsType" class="inputText">Provider performance monitoring</span><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsOtherNamelblDiv"><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsNameLbl" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsName"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:panel_dsName"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsName" class="inputTextPct"></span></div></div></div><table id="svapdxAQ_1:dtPMPrnt: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="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsrp1"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:PMrp1div" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsRpSma" type="checkbox" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:lbl_dsRpSma" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsRpSma" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsfom1"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsFdWkdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsFdWk" type="checkbox" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:lbl_dsFdWk" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsFdWk" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dssa1"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsSaPctdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsSaPct" type="checkbox" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsSaPct" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:lbl_dsSaPct" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsSaPct" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsrp2"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsRpOpadiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsRpOpa" type="checkbox" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:lbl_dsRpOpa" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsRpOpa" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsfom2"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsFdModiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsFdMo" type="checkbox" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:lbl_dsFdMo" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsFdMo" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dssa2"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsSaLtPct" type="checkbox" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsSaLtPct" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:lbl_dsSaLtPct" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsSaLtPct" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1: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:1:dsrp3"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsRpCmadiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsRpCma" type="checkbox" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:lbl_dsRpCma" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsRpCma" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsfom3"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsFdQudiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsFdQu" type="checkbox" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:lbl_dsFdQu" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsFdQu" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dssa3" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsSaRsdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsSaRs" type="checkbox" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:lbl_dsSaRs" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsSaRs" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:lbl2_dsSaRsDsc" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsSaRsDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:panel_dsSaRsDsc"><textarea id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsSaRsDsc" name="svapdxAQ_1:dtPMPrnt: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="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsrp4"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsRpOthdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsRpOth" type="checkbox" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:lbl_dsRpOth" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsRpOth" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:lbl2_dsRpOthDsc" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsRpOthDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:panel_dsRpOthDsc"><textarea id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsRpOthDsc" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsRpOthDsc" class="inputTextarea" readonly="readonly">contracted Access Agency</textarea></span></div></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsfom4"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsFdAndiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsFdAn" type="checkbox" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:lbl_dsFdAn" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsFdAn" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dssa4" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsSaStrdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsSaStr" type="checkbox" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:lbl_dsSaStr" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsSaStr" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:lbl2_dsSaStrDsc" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsSaStrDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:panel_dsSaStrDsc"><textarea id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsSaStrDsc" name="svapdxAQ_1:dtPMPrnt: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="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsrp5"></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsfom5"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsFdCodiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsFdCo" type="checkbox" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsFdCo" checked="checked" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:lbl_dsFdCo" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsFdCo" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dssa5" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsSaOthdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsSaOth" type="checkbox" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsSaOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:lbl_dsSaOth" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsSaOth" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:lbl2_dsSaOthDsc" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsSaOthDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:panel_dsSaOthDsc"><textarea id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsSaOthDsc" name="svapdxAQ_1:dtPMPrnt: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="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsrp6"></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsfom6"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsFdOtdiv" class="checkboxGroup"><input id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsFdOt" type="checkbox" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:lbl_dsFdOt" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsFdOt" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:lbl2_dsFdOtDsc" for="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsFdOtDsc" class="outputLabel"> <span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:panel_dsFdOtDsc"><textarea id="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsFdOtDsc" name="svapdxAQ_1:dtPMPrnt:0:svQmPerfMeas:dtDataSource:1:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxAQ_1:dtPMPrnt: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="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" checked="checked" 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" 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" 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" disabled="disabled" readonly="readonly"></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" checked="checked" 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" readonly="readonly">Every 18 months</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 percentage of required aggregate reports recieved from the Access Agencies in the time frame required in their contract. Numerator=number of reports received on time and denominator is total number of reports due</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">Reports to State Medicaid Agency on delegated Administrative functions</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" checked="checked" 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" checked="checked" 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">contracted entity</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" checked="checked" 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" checked="checked" 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" checked="checked" 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" 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" disabled="disabled" readonly="readonly"></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" checked="checked" 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> </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">ACU unit staff meetings are held as needed to collaborate and diseminate information with regards to waiver functions. Access Agency meetings are held on a bi-monthly basis. These meetings are used as a forum to exchange information and identify any problems/issues or trends occuring in the waiver program. Multiple levels of record review occur on a regular basis. The Access Agency supervisors review records and the Department is requiring that a uniform tool be established for aggregate quarterly reporting to the Department. The Access Agencies also have an external quarterly audit process where outside professionals perform record reviews. That data is provided to the Department in an annual summary report. In addition, department staff perform record audits of all the Access Agencies on a rotating basis to measure compliance with contract deliverables and quality of care provided to waiver participants. Sampling of chart reviews is not a representative sample. Remediation is to increse the number of client chart reviews to reduce the margin of error and increase our confidence 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="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">When problems are identified, communications both written and within meetings provide opportunities for resolution of issues of concern. Audits result in issuance of formal reports and minutes are generated for meetings.</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" checked="checked" 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" 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"></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" checked="checked" 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" value="65" 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" checked="checked" 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" 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" class="inputText" readonly="readonly" /> </TD> <TD headers="maxAge thruAge"> <input id="svapdxB1_1:tgagDisPhyMax" type="text" name="svapdxB1_1:tgagDisPhyMax" 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"></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" checked="checked" 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" 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"></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 125% of the average Medicaid cost of nursing home effective 7/1/18 and to 130% 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 refers the prospective client to an Access Agency for the initial assessment and development of the plan of care. The care manager is responsible to develop the plan to maintain the client's health and safety while staying within the cost cap specified in the waiver. This is done in consultation with the client and/or their responsible party. The development of the care plan is based on a multidimensional assessment that covers the domains of health, function, psychosocial, cognition, environment, support system and finances. Risk factors are identified and mitigated through service plans. Once the plan is agreed upon, the costs are determined. Each service on the plan of care is evaluated to determine if a back-up plan is necessary to ensure client health and/or safety. If an applicant's health and safety needs cannot be met, they are denied access to the waiver. The applicant, if denied, receives a Medicaid Notice of Action (NOA) advising of their rights to a hearing. Any plan that exceeds 100% (inclusive)of the average cost of nursing home are subject to prior authorization by HCBS Unit nurses.</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">Services beyond the monthly cap may be authorized on a short term basis to meet health and safety needs as long as there is evidence that the plan on an annualized basis will be equal to or less than 115% of the cost of nursing facility care. Applicants whose needs cannot be met within the caps are assisted in accessing other state plan services but are determined to be ineligible for the waiver. The client is issued a NOA and advised of their right to a fair hearing. Services are continued at the client's request while the hearing decision is pending. Clients are given a minimum of 10 days notice of any adverse action.</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="15549" 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="16493" 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="17354" 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="18136" 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="18858" 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%;">Transitions from PCA Waiver</span></td> <td ></td> </tr> <tr ><td ><span id="svapdxB3_2:PurposeTb:1:purposePrpTtl" class="outputText" style="width: 95%;">Transitions from MFP</span></td> <td ></td> </tr> <tr ><td ><span id="svapdxB3_2:PurposeTb:2:purposePrpTtl" class="outputText" style="width: 95%;">Transitions from the 1915 i HCBS State Plan Option</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">Transitions from PCA Waiver</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">The state reserves capacity to accommodate persons mandated to transition from the PCA Waiver when they turn 65.</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">The estimate is based on the current enrollees expected to turn 65 in the next two waiver 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="48" 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="48" 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="48" 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="48" 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="48" 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> <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:1:svapdxB3_2a_prnt:lblprpTtl" for="svapdxB3_2_prnt:PurposePrnt:1:svapdxB3_2a_prnt:prpTtl" class="outputLabel"> <span id="svapdxB3_2_prnt:PurposePrnt:1:svapdxB3_2a_prnt:lbltxtprpTtl" class="outputText">Purpose </span><span id="svapdxB3_2_prnt:PurposePrnt:1: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:1:svapdxB3_2a_prnt:panel_prpTtl"><textarea id="svapdxB3_2_prnt:PurposePrnt:1:svapdxB3_2a_prnt:prpTtl" name="svapdxB3_2_prnt:PurposePrnt:1:svapdxB3_2a_prnt:prpTtl" class="inputTextarea" readonly="readonly">Transitions from MFP</textarea></span> </div> <div class="firstIndent"> <p> <label id="svapdxB3_2_prnt:PurposePrnt:1:svapdxB3_2a_prnt:lblprpDscr" for="svapdxB3_2_prnt:PurposePrnt:1:svapdxB3_2a_prnt:prpDscr" class="outputLabel"> <span id="svapdxB3_2_prnt:PurposePrnt:1:svapdxB3_2a_prnt:lbltxtprpDscr" class="outputText">Purpose </span><span id="svapdxB3_2_prnt:PurposePrnt:1:svapdxB3_2a_prnt:lbltxtprpDscr2" class="outputTextNB em"> (describe):</span></label> </p> <div class="inputTextareaWA"> <span id="svapdxB3_2_prnt:PurposePrnt:1:svapdxB3_2a_prnt:panel_prpDscr"><textarea id="svapdxB3_2_prnt:PurposePrnt:1:svapdxB3_2a_prnt:prpDscr" name="svapdxB3_2_prnt:PurposePrnt:1:svapdxB3_2a_prnt:prpDscr" class="inputTextarea" readonly="readonly">The state reserves 184 slots in year 4 of the waiver and 241 slots in year 5 to accommodate transitions from the Money Follows the Person Demonstration.</textarea></span> </div> <p> <label id="svapdxB3_2_prnt:PurposePrnt:1:svapdxB3_2a_prnt:lblprpCapDscr" for="svapdxB3_2_prnt:PurposePrnt:1:svapdxB3_2a_prnt:prpCapDscr" class="outputLabel"> <span id="svapdxB3_2_prnt:PurposePrnt:1: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:1:svapdxB3_2a_prnt:panel_prpCapDscr"><textarea id="svapdxB3_2_prnt:PurposePrnt:1:svapdxB3_2a_prnt:prpCapDscr" name="svapdxB3_2_prnt:PurposePrnt:1:svapdxB3_2a_prnt:prpCapDscr" class="inputTextarea" readonly="readonly">Based on the average number of transitions and current applications as well as historical trends.</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:1:svapdxB3_2a_prnt:yr1" type="text" name="svapdxB3_2_prnt:PurposePrnt:1:svapdxB3_2a_prnt:yr1" value="245" class="inputText" readonly="readonly" /> </td> </tr> <tr> <td headers="wr" class="desc">Year 2</td> <td headers="cr"> <input id="svapdxB3_2_prnt:PurposePrnt:1:svapdxB3_2a_prnt:yr2" type="text" name="svapdxB3_2_prnt:PurposePrnt:1:svapdxB3_2a_prnt:yr2" value="291" class="inputText" readonly="readonly" /> </td> </tr> <tr> <td headers="wr" class="desc">Year 3</td> <td headers="cr"> <input id="svapdxB3_2_prnt:PurposePrnt:1:svapdxB3_2a_prnt:yr3" type="text" name="svapdxB3_2_prnt:PurposePrnt:1:svapdxB3_2a_prnt:yr3" value="304" class="inputText" readonly="readonly" /> </td> </tr> <tr> <td headers="wr" class="desc">Year 4</td> <td headers="cr"> <input id="svapdxB3_2_prnt:PurposePrnt:1:svapdxB3_2a_prnt:yr4" type="text" name="svapdxB3_2_prnt:PurposePrnt:1:svapdxB3_2a_prnt:yr4" value="316" class="inputText" readonly="readonly" /> </td> </tr> <tr> <td headers="wr" class="desc">Year 5</td> <TD headers="cr"> <input id="svapdxB3_2_prnt:PurposePrnt:1:svapdxB3_2a_prnt:yr5" type="text" name="svapdxB3_2_prnt:PurposePrnt:1:svapdxB3_2a_prnt:yr5" value="328" 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> <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:2:svapdxB3_2a_prnt:lblprpTtl" for="svapdxB3_2_prnt:PurposePrnt:2:svapdxB3_2a_prnt:prpTtl" class="outputLabel"> <span id="svapdxB3_2_prnt:PurposePrnt:2:svapdxB3_2a_prnt:lbltxtprpTtl" class="outputText">Purpose </span><span id="svapdxB3_2_prnt:PurposePrnt:2: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:2:svapdxB3_2a_prnt:panel_prpTtl"><textarea id="svapdxB3_2_prnt:PurposePrnt:2:svapdxB3_2a_prnt:prpTtl" name="svapdxB3_2_prnt:PurposePrnt:2:svapdxB3_2a_prnt:prpTtl" class="inputTextarea" readonly="readonly">Transitions from the 1915 i HCBS State Plan Option</textarea></span> </div> <div class="firstIndent"> <p> <label id="svapdxB3_2_prnt:PurposePrnt:2:svapdxB3_2a_prnt:lblprpDscr" for="svapdxB3_2_prnt:PurposePrnt:2:svapdxB3_2a_prnt:prpDscr" class="outputLabel"> <span id="svapdxB3_2_prnt:PurposePrnt:2:svapdxB3_2a_prnt:lbltxtprpDscr" class="outputText">Purpose </span><span id="svapdxB3_2_prnt:PurposePrnt:2:svapdxB3_2a_prnt:lbltxtprpDscr2" class="outputTextNB em"> (describe):</span></label> </p> <div class="inputTextareaWA"> <span id="svapdxB3_2_prnt:PurposePrnt:2:svapdxB3_2a_prnt:panel_prpDscr"><textarea id="svapdxB3_2_prnt:PurposePrnt:2:svapdxB3_2a_prnt:prpDscr" name="svapdxB3_2_prnt:PurposePrnt:2:svapdxB3_2a_prnt:prpDscr" class="inputTextarea" readonly="readonly">The state serves CT residents 65 and older who are less than nursing facility level of care under a 1915i state plan option.</textarea></span> </div> <p> <label id="svapdxB3_2_prnt:PurposePrnt:2:svapdxB3_2a_prnt:lblprpCapDscr" for="svapdxB3_2_prnt:PurposePrnt:2:svapdxB3_2a_prnt:prpCapDscr" class="outputLabel"> <span id="svapdxB3_2_prnt:PurposePrnt:2: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:2:svapdxB3_2a_prnt:panel_prpCapDscr"><textarea id="svapdxB3_2_prnt:PurposePrnt:2:svapdxB3_2a_prnt:prpCapDscr" name="svapdxB3_2_prnt:PurposePrnt:2:svapdxB3_2a_prnt:prpCapDscr" class="inputTextarea" readonly="readonly">Historically, as these residents age in place, some of them experience increased care needs resulting in functional eligibility for the waiver. We estimate, based on historical trends that an average of 10% of the 1915i recipients will have increased care needs that result in waiver eligibility.</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:2:svapdxB3_2a_prnt:yr1" type="text" name="svapdxB3_2_prnt:PurposePrnt:2:svapdxB3_2a_prnt:yr1" value="95" class="inputText" readonly="readonly" /> </td> </tr> <tr> <td headers="wr" class="desc">Year 2</td> <td headers="cr"> <input id="svapdxB3_2_prnt:PurposePrnt:2:svapdxB3_2a_prnt:yr2" type="text" name="svapdxB3_2_prnt:PurposePrnt:2:svapdxB3_2a_prnt:yr2" value="100" class="inputText" readonly="readonly" /> </td> </tr> <tr> <td headers="wr" class="desc">Year 3</td> <td headers="cr"> <input id="svapdxB3_2_prnt:PurposePrnt:2:svapdxB3_2a_prnt:yr3" type="text" name="svapdxB3_2_prnt:PurposePrnt:2:svapdxB3_2a_prnt:yr3" value="103" class="inputText" readonly="readonly" /> </td> </tr> <tr> <td headers="wr" class="desc">Year 4</td> <td headers="cr"> <input id="svapdxB3_2_prnt:PurposePrnt:2:svapdxB3_2a_prnt:yr4" type="text" name="svapdxB3_2_prnt:PurposePrnt:2:svapdxB3_2a_prnt:yr4" value="105" class="inputText" readonly="readonly" /> </td> </tr> <tr> <td headers="wr" class="desc">Year 5</td> <TD headers="cr"> <input id="svapdxB3_2_prnt:PurposePrnt:2:svapdxB3_2a_prnt:yr5" type="text" name="svapdxB3_2_prnt:PurposePrnt:2:svapdxB3_2a_prnt:yr5" value="110" 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">Applications are processed on a first come first serve basis. There is no waiting list for the waiver program. Applicants are screened by department HCBS Unit nurses and social workers for level of care, financial eligibility, and whose care needs are consistent with the need for institutionalization. Applicants must meet nursing facility level of care to be included in the waiver.</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" 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">Persons defined as qualified severely impaired individuals in section 1619(b) 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 State does not furnish waiver services to individuals in the special home and community-based waiver group under 42 CFR §435.217.</strong> <em>Appendix B-5 is not submitted.</em></span> </div> <div class="checkboxGroup"> <label><input id="svapdxB4_1:elgGrpSpecHomCom:1" type="radio" name="svapdxB4_1:elgGrpSpecHomCom" checked="checked" value="1" onclick="return callSave(this, event);" disabled="disabled" />&#160;Yes.</label> <span class="outputTextNB"> <strong>The State furnishes waiver services to individuals in the special home and community-based waiver group under 42 CFR §435.217.</strong></span> </div> <div class="noShow"><label><input id="svapdxB4_1:elgGrpSpecHomCom:2" type="radio" name="svapdxB4_1:elgGrpSpecHomCom" value="99" onclick="return callSave(this, event);" disabled="disabled" />&#160;not selected</label></div> </div> <!-- rendered="#{(varFactory.elgGrpSpecHomCom == 1)?true:false}"> --> <div class="firstIndent"> <p><label for="template:elgGrp435Type" id="lbl_elgGrp435Type" 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" checked="checked" 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" 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"></textarea></span> </div> </div> <div class="checkboxGroup"><label><input id="svapdxB5_3:elgIncPtcAlwType:3" type="radio" name="svapdxB5_3:elgIncPtcAlwType" checked="checked" 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">200% of the Federal Poverty Level</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" checked="checked" 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" 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"></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" checked="checked" 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" 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" 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"></textarea></span> </div> </div> <div class="checkboxGroup"> <label><input id="svapdxB6_1:elgEvalRespType:3" type="radio" name="svapdxB6_1:elgEvalRespType" checked="checked" 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">The initial Level of Care evaluation is performed by nurses and social workers employed by DSS in the HCBS Unit utilizing a uniform health screen. The client is referred to the Access Agency that performs a comprehensive assessment and submits a summary of that assessment to the Department's Utilization Review staff for review to confirm the level of care. Level of care reevaluations are conducted by Access Agency Care Managers with oversight by the Department's Utilization Review staff.</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">HCBS Unit staff that conduct the inital 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, 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. 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">A Uniform Health Screen is utilized to determine nursing facility level of care. Nursing Facility Level of Care is defined as an individual requiring substantial daily assistance as defined by the following criteria: Substantial daily personal care is defined by: 1. Supervision or cueing &#8805; 3 ADLs daily + need factor 2. Hands-on &#8805; 3 ADLs daily 3. Hands-on &#8805; 2 ADLs daily + need factor 4. A cognitive impairment which requires a professionally staffed environment for monitoring on a daily basis. Need factors are: 1. Cognitive Need: Requires daily supervision to prevent harm due to a cognitive impairment 2. Behavioral Need: Requires daily supervision to prevent harm 3. Medication supports: Requires assistance for administration of physician ordered daily medications. Includes supports beyond set up. For the nursing facility sub-acute level of care, the individual would meet all of the above criteria with the addition of the need for comprehensive medical monitoring, intensive medical supervision such as intermittent nursing services throughout the day or have high intensity rehabilitative needs, are ventilator dependent, have complex wound care needs or a need for specialized infusion therapy.</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" checked="checked" 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" 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"></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">The same care manager who conducts the initial evaluation visits the client for the annual reevaluation and conducts a comprehensive, multidimensional assessment. The assessment covers seven domains: health, function, psychosocial, cognition, support system, environment and finances. The assessment identifies unmet needs and risk factors. After completion of the assessment, they are required to specify the level of care based on the findings of the reevaluation. The department reviews a random sample of reevaluations that summarize the reevaluation findings. Plans of care are also reviewed to evaluate if services meet the identified needs.</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 callSave(this, event);" disabled="disabled" />&#160;Every twelve months </label></div> <div class="checkboxGroup"><label><input id="svapdxB6_1:elgRevalSchType:3" type="radio" name="svapdxB6_1:elgRevalSchType" value="3" onclick="return callSave(this, event);" disabled="disabled" />&#160;Other schedule</label></div> <div class="firstIndent"> <label id="svapdxB6_1:lblelgRevalSchOthDscr" for="svapdxB6_1:elgRevalSchOthDscr" class="outputLabel"> <span id="svapdxB6_1:lbltxtelgRevalSchOthDscr" class="outputTextNB em">Specify the other schedule:</span></label> <p></p> <div class="chrCntDiv"> <label id="svapdxB6_1:elgRevalSchOthDscrChrCntLbl" for="svapdxB6_1:elgRevalSchOthDscrChrCnt" class="outputLabel"> <span id="svapdxB6_1:elgRevalSchOthDscrChrCntLblTxt" class="chrCnt">Character Count:</span></label><input id="svapdxB6_1:elgRevalSchOthDscrChrCnt" type="text" name="svapdxB6_1:elgRevalSchOthDscrChrCnt" class="chrCnt" size="6" /><span id="svapdxB6_1:elgRevalSchOthDscrChrCntMax" class="chrCnt"> 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">The department maintains an electronic database of all clients and their reevaluation schedule. Six weeks prior to the beginning of the month when reevaluations are due, the Department sends the list of reevaluations due to be completed. Compliance with this is also audited by the Department via record review.</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">Records are retained in both the HCBS Unit of the Department of Social Services as well as in the offices of the Access Agencies. The Department's policy for record retention is seven years.</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">Number and percent of applicants who receive an initial telephone level of care screening by clinical staff of the HCBS unit to validate the need for institutional level of care prior to the reciept of services. N= # of applicants who receive phone LOC screening D= # of applicants</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">Analyzed collected data (including surveys, focus group, interviews, etc)</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" 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" checked="checked" 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> </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">Number and percent of clients for whom HCBS clinical staff reviews reassessment summary data for accuracy of level of care. N= # client whose RA data is reviewed D= # clients who are reassessed</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">Analyzed collected data (including surveys, focus group, interviews, etc)</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"></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" 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" checked="checked" 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" checked="checked" 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" 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" checked="checked" 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" readonly="readonly">contracted access agencies</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" checked="checked" 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" readonly="readonly">10% of reassessments due each month</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" 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" disabled="disabled" readonly="readonly"></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" checked="checked" 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" 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> <tr ><td > <div style="padding-bottom: 1.5em; width:90%;" > <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:pmName" class="inputTextPct">Number and percent of clients who are reevaluated at least annually for level of care. N= # of clients reviewed annually for LOC D=# of clients with annual review due</span> </div> </div> <table id="svapdxBQ_1:dtPMPrnt_locb: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="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Reports to State Medicaid Agency on delegated</span><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct"></span></div></div></div><table id="svapdxBQ_1:dtPMPrnt_locb: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="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsRpSma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsSaPct" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1: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:1:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1: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:1:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxBQ_1:dtPMPrnt_locb: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="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="inputTextarea" readonly="readonly">contracted Access Agencies</textarea></span></div></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsFdAn" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxBQ_1:dtPMPrnt_locb: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="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsFdCo" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsSaOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxBQ_1:dtPMPrnt_locb: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="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:0:dssa6"></span></td> </tr> </tbody> </table> </td> </tr> <tr ><td ><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsTypeLbl" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsType"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsTypeDDDiv"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsType" class="inputText">Record reviews, on-site</span><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsOtherNamelblDiv"><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsNameLbl" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsName"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:panel_dsName"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsName" class="inputTextPct"></span></div></div></div><table id="svapdxBQ_1:dtPMPrnt_locb:1: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_locb:1:svQmPerfMeas:dtDataSource:1:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsrp1"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:PMrp1div" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsRpSma" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:lbl_dsRpSma" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsRpSma" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsfom1"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsFdWkdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsFdWk" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:lbl_dsFdWk" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsFdWk" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dssa1"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsSaPctdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsSaPct" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsSaPct" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:lbl_dsSaPct" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsSaPct" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsrp2"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsRpOpadiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsRpOpa" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:lbl_dsRpOpa" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsRpOpa" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsfom2"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsFdModiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsFdMo" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:lbl_dsFdMo" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsFdMo" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dssa2"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsSaLtPct" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsSaLtPct" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:lbl_dsSaLtPct" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsSaLtPct" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1: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_locb:1:svQmPerfMeas:dtDataSource:1:dsrp3"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsRpCmadiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsRpCma" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:lbl_dsRpCma" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsRpCma" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsfom3"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsFdQudiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsFdQu" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsFdQu" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:lbl_dsFdQu" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsFdQu" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dssa3" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsSaRsdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsSaRs" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:lbl_dsSaRs" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsSaRs" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:lbl2_dsSaRsDsc" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsSaRsDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:panel_dsSaRsDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsSaRsDsc" name="svapdxBQ_1:dtPMPrnt_locb:1: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_locb:1:svQmPerfMeas:dtDataSource:1:dsrp4"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsRpOthdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsRpOth" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:lbl_dsRpOth" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsRpOth" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:lbl2_dsRpOthDsc" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsRpOthDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:panel_dsRpOthDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsRpOthDsc" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsRpOthDsc" class="inputTextarea" readonly="readonly">contracted entity</textarea></span></div></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsfom4"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsFdAndiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsFdAn" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:lbl_dsFdAn" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsFdAn" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dssa4" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsSaStrdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsSaStr" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:lbl_dsSaStr" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsSaStr" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:lbl2_dsSaStrDsc" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsSaStrDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:panel_dsSaStrDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsSaStrDsc" name="svapdxBQ_1:dtPMPrnt_locb:1: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_locb:1:svQmPerfMeas:dtDataSource:1:dsrp5"></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsfom5"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsFdCodiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsFdCo" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsFdCo" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:lbl_dsFdCo" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsFdCo" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dssa5" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsSaOthdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsSaOth" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsSaOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:lbl_dsSaOth" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsSaOth" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:lbl2_dsSaOthDsc" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsSaOthDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:panel_dsSaOthDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsSaOthDsc" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsSaOthDsc" class="inputTextarea" readonly="readonly">5% of all records will have a supervisory review</textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsrp6"></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsfom6"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsFdOtdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsFdOt" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:lbl_dsFdOt" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsFdOt" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:lbl2_dsFdOtDsc" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsFdOtDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:panel_dsFdOtDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsFdOtDsc" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:dtDataSource:1:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:1: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_locb: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="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxBQ_1:dtPMPrnt_locb: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="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:pmDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:pmDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:pmDaFdQu" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:pmDaRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:pmDaRpOthDsc" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:pmDaRpOthDsc" class="inputTextarea" readonly="readonly">contracted Access Agencies</textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:pmDaFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb: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="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:pmDaFdCo" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb: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="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:pmDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locb:1:svQmPerfMeas:pmDaFdOtDsc" name="svapdxBQ_1:dtPMPrnt_locb: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="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:pmName" class="inputTextPct">Number and percent of participants whose total plan of care has been modified to reflect significant changes in the participants'condition. N= # of clients whose plans were modified D= # of clients who had needs change requiring plan modification</span> </div> </div> <table id="svapdxBQ_1:dtPMPrnt_locb: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="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Record reviews, on-site</span><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct"></span></div></div></div><table id="svapdxBQ_1:dtPMPrnt_locb: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="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsRpSma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsSaPct" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2: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:2:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsSaLtPct" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2: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:2:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxBQ_1:dtPMPrnt_locb: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="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="inputTextarea" readonly="readonly">contracted entity</textarea></span></div></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxBQ_1:dtPMPrnt_locb: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="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsFdCo" checked="checked" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsSaOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="inputTextarea" readonly="readonly">5% of records each quarter</textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:0:dssa6"></span></td> </tr> </tbody> </table> </td> </tr> <tr ><td ><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsTypeLbl" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsType"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsTypeDDDiv"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsType" class="inputText">Record reviews, on-site</span><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsOtherNamelblDiv"><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsNameLbl" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsName"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:panel_dsName"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsName" class="inputTextPct"></span></div></div></div><table id="svapdxBQ_1:dtPMPrnt_locb:2: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_locb:2:svQmPerfMeas:dtDataSource:1:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsrp1"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:PMrp1div" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsRpSma" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:lbl_dsRpSma" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsRpSma" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsfom1"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsFdWkdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsFdWk" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:lbl_dsFdWk" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsFdWk" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dssa1"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsSaPctdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsSaPct" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsSaPct" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:lbl_dsSaPct" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsSaPct" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsrp2"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsRpOpadiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsRpOpa" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:lbl_dsRpOpa" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsRpOpa" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsfom2"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsFdModiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsFdMo" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:lbl_dsFdMo" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsFdMo" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dssa2"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsSaLtPct" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsSaLtPct" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:lbl_dsSaLtPct" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsSaLtPct" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2: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_locb:2:svQmPerfMeas:dtDataSource:1:dsrp3"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsRpCmadiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsRpCma" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:lbl_dsRpCma" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsRpCma" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsfom3"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsFdQudiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsFdQu" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:lbl_dsFdQu" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsFdQu" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dssa3" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsSaRsdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsSaRs" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:lbl_dsSaRs" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsSaRs" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:lbl2_dsSaRsDsc" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsSaRsDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:panel_dsSaRsDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsSaRsDsc" name="svapdxBQ_1:dtPMPrnt_locb:2: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_locb:2:svQmPerfMeas:dtDataSource:1:dsrp4"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsRpOthdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsRpOth" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:lbl_dsRpOth" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsRpOth" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:lbl2_dsRpOthDsc" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsRpOthDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:panel_dsRpOthDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsRpOthDsc" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsRpOthDsc" class="inputTextarea" readonly="readonly">contracted entity</textarea></span></div></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsfom4"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsFdAndiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsFdAn" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:lbl_dsFdAn" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsFdAn" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dssa4" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsSaStrdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsSaStr" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:lbl_dsSaStr" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsSaStr" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:lbl2_dsSaStrDsc" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsSaStrDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:panel_dsSaStrDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsSaStrDsc" name="svapdxBQ_1:dtPMPrnt_locb:2: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_locb:2:svQmPerfMeas:dtDataSource:1:dsrp5"></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsfom5"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsFdCodiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsFdCo" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsFdCo" checked="checked" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:lbl_dsFdCo" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsFdCo" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dssa5" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsSaOthdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsSaOth" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsSaOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:lbl_dsSaOth" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsSaOth" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:lbl2_dsSaOthDsc" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsSaOthDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:panel_dsSaOthDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsSaOthDsc" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsSaOthDsc" class="inputTextarea" readonly="readonly">non-representative sample of each Access Agency every 18 months</textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsrp6"></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsfom6"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsFdOtdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsFdOt" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:lbl_dsFdOt" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsFdOt" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:lbl2_dsFdOtDsc" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsFdOtDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:panel_dsFdOtDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsFdOtDsc" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:dtDataSource:1:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locb:2: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_locb: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="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxBQ_1:dtPMPrnt_locb: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="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:pmDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:pmDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:pmDaFdQu" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:pmDaRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:pmDaRpOthDsc" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:pmDaRpOthDsc" class="inputTextarea" readonly="readonly">contracted agency</textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:pmDaFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb: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="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:pmDaFdCo" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb: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="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:pmDaFdOt" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:pmDaFdOtDsc" name="svapdxBQ_1:dtPMPrnt_locb:2:svQmPerfMeas:pmDaFdOtDsc" class="inputTextarea" readonly="readonly">every 18 months</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 waiver participants who are assessed and reassessed utilizing department's required assessment instrument N= # of clients assessed and reassessed using department's tool D= # of clients assessed and reassessed</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">Analyzed collected data (including surveys, focus group, interviews, etc)</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" 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" checked="checked" 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" readonly="readonly">contracted entity</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" checked="checked" 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" 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> <tr ><td > <div style="padding-bottom: 1.5em; width:90%;" > <span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:pmName" class="inputTextPct">Number and percent of initial level of care determinations that are made by HCBS clinical staff utilizing standardized forms and approved procedures. Each applicant is screened to determine that they meet both the funcional and financial criteria for participation in the waiver. N= # of clients reviewed using approved forms D= number of clients reviewed</span> </div> </div> <table id="svapdxBQ_1:dtPMPrnt_locc: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="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Other</span><div id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct">standardized forms maintained in program electronic data base</span></div></div></div><table id="svapdxBQ_1:dtPMPrnt_locc: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="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsSaPct" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:1: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:1:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:1: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:1:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxBQ_1:dtPMPrnt_locc: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="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxBQ_1:dtPMPrnt_locc:1: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:1:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxBQ_1:dtPMPrnt_locc: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="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsFdCo" checked="checked" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsSaOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxBQ_1:dtPMPrnt_locc: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="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxBQ_1:dtPMPrnt_locc:1: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: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="svapdxBQ_1:dtPMPrnt_locc: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="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxBQ_1:dtPMPrnt_locc: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="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:pmDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:pmDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:pmDaFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:pmDaRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:pmDaRpOthDsc" name="svapdxBQ_1:dtPMPrnt_locc:1: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:1:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:pmDaFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc: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="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:pmDaFdCo" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc: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="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:pmDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxBQ_1:dtPMPrnt_locc:1:svQmPerfMeas:pmDaFdOtDsc" name="svapdxBQ_1:dtPMPrnt_locc: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="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">Every client who is seeking waiver services is initially screened for Level of Care by HCBS Unit Clinical staff. The level of care is confimed by the Access Agency staff when completing the comprehensive, initial face to face assessment. The HCBS Unit conducts onsite or desk audit reviews of access agency and Assisted Living client records. Client in-home visits are conducted by HCBS Unit Quality Assurance staff on a sampling of both Access Agency and Assisted Living clients. Onsite visits to waiver service providers are also made to collect information. Client satisfaction surveys are conducted to allow individuals a means to provide feedback on the quality of the services received. The Home Care Advisory Committee, comprised of a wide range of providers and advocates and a client representative, meets semi-annually with Department staff to discuss current issues affecting elders statewide.</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">Individual concerns regarding the health and safety of clients is reported to QA staff. QA staff investigate the basis of the complaint/referral, consult with the Unit Manager, and make a determination if corrective action is pursued by the access agency or ALSA. QA staff monitors until a satisfactory resolution is achieved. Any final recommendations are made in consultation with the manager. Aditionally, QA staff monitor non health and safety complaints until satifactory resolution is obtained. The department maintains a web based critical incident reporting system that allows for identification and remediation of individual problems</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" checked="checked" 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" checked="checked" 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" 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"></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">As part of the inital evaluation conducted by the care manager, the client is offered a choice of a home and community based service plan or institutional services. Each client is asked to sign an Informed Consent form (W-889) where they are advised of their choice between community services or institutional care. They are advised that an assessment must be completed in order to access services under the waiver. A copy of the consent form is left with the client. The care manager also informs the individual about the range of services available under the waiver and the available providers.</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">The freedom of choice form W-889 is retained in the client's record for seven years. The form is maintained in the Access Agencies records and is audited for in the department's annual audit.</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 home care request form is available in Spanish. The HCBS Unit has Spanish speaking staff to handle inquiries and referrals to the program. The Department also has language line services available with interpreters for a wide array of languages. The Access Agencies have bilingual case managers including Spanish, Russian, Italian and French. Non-English speaking waiver applicants may bring an interpreter of their choice to any meeting with the case manager. This is not a requirement but an option available to clients should they so choose. No person can be denied access to waiver services 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="223092" 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">Adult Day Health</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="223164" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1:dtServices:1:serviceType" class="outputText">Statutory Service</span></td> <td ><span id="svapdxC1_1:dtServices:1:serviceName" class="outputText">Care Management</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="223172" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1:dtServices:2:serviceType" class="outputText">Statutory Service</span></td> <td ><span id="svapdxC1_1:dtServices:2:serviceName" class="outputText">Homemaker</span></td> <td ></td> <td ></td> </tr> <tr ><td ><input id="svapdxC1_1:dtServices:3:serviceID" type="text" name="svapdxC1_1:dtServices:3:serviceID" value="226274" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1:dtServices:3:serviceType" class="outputText">Statutory Service</span></td> <td ><span id="svapdxC1_1:dtServices:3:serviceName" class="outputText">Personal Care Assistant</span></td> <td ></td> <td ></td> </tr> <tr ><td ><input id="svapdxC1_1:dtServices:4:serviceID" type="text" name="svapdxC1_1:dtServices:4:serviceID" value="223233" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1:dtServices:4:serviceType" class="outputText">Statutory Service</span></td> <td ><span id="svapdxC1_1:dtServices:4:serviceName" class="outputText">Respite</span></td> <td ></td> <td ></td> </tr> <tr ><td ><input id="svapdxC1_1:dtServices:5:serviceID" type="text" name="svapdxC1_1:dtServices:5:serviceID" value="225553" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1:dtServices:5:serviceType" class="outputText">Supports for Participant Direction</span></td> <td ><span id="svapdxC1_1:dtServices:5:serviceName" class="outputText">Independent Support Broker</span></td> <td ></td> <td ></td> </tr> <tr ><td ><input id="svapdxC1_1:dtServices:6:serviceID" type="text" name="svapdxC1_1:dtServices:6:serviceID" value="223227" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1:dtServices:6:serviceType" class="outputText">Other Service</span></td> <td ><span id="svapdxC1_1:dtServices:6:serviceName" class="outputText">Adult Family Living/Foster Care</span></td> <td ></td> <td ></td> </tr> <tr ><td ><input id="svapdxC1_1:dtServices:7:serviceID" type="text" name="svapdxC1_1:dtServices:7:serviceID" value="223108" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1:dtServices:7:serviceType" class="outputText">Other Service</span></td> <td ><span id="svapdxC1_1:dtServices:7:serviceName" class="outputText">Assisted Living</span></td> <td ></td> <td ></td> </tr> <tr ><td ><input id="svapdxC1_1:dtServices:8:serviceID" type="text" name="svapdxC1_1:dtServices:8:serviceID" value="223153" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1:dtServices:8:serviceType" class="outputText">Other Service</span></td> <td ><span id="svapdxC1_1:dtServices:8:serviceName" class="outputText">Assistive Technology</span></td> <td ></td> <td ></td> </tr> <tr ><td ><input id="svapdxC1_1:dtServices:9:serviceID" type="text" name="svapdxC1_1:dtServices:9:serviceID" value="225398" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1:dtServices:9:serviceType" class="outputText">Other Service</span></td> <td ><span id="svapdxC1_1:dtServices:9:serviceName" class="outputText">Bill Payer</span></td> <td ></td> <td ></td> </tr> <tr ><td ><input id="svapdxC1_1:dtServices:10:serviceID" type="text" name="svapdxC1_1:dtServices:10:serviceID" value="225396" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1:dtServices:10:serviceType" class="outputText">Other Service</span></td> <td ><span id="svapdxC1_1:dtServices:10:serviceName" class="outputText">Care Transitions</span></td> <td ></td> <td ></td> </tr> <tr ><td ><input id="svapdxC1_1:dtServices:11:serviceID" type="text" name="svapdxC1_1:dtServices:11:serviceID" value="223238" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1:dtServices:11:serviceType" class="outputText">Other Service</span></td> <td ><span id="svapdxC1_1:dtServices:11:serviceName" class="outputText">Chore Services</span></td> <td ></td> <td ></td> </tr> <tr ><td ><input id="svapdxC1_1:dtServices:12:serviceID" type="text" name="svapdxC1_1:dtServices:12:serviceID" value="225397" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1:dtServices:12:serviceType" class="outputText">Other Service</span></td> <td ><span id="svapdxC1_1:dtServices:12:serviceName" class="outputText">Chronic Disease Self-Management Program</span></td> <td ></td> <td ></td> </tr> <tr ><td ><input id="svapdxC1_1:dtServices:13:serviceID" type="text" name="svapdxC1_1:dtServices:13:serviceID" value="223180" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1:dtServices:13:serviceType" class="outputText">Other Service</span></td> <td ><span id="svapdxC1_1:dtServices:13:serviceName" class="outputText">Companion</span></td> <td ></td> <td ></td> </tr> <tr ><td ><input id="svapdxC1_1:dtServices:14:serviceID" type="text" name="svapdxC1_1:dtServices:14:serviceID" value="223130" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1:dtServices:14:serviceType" class="outputText">Other Service</span></td> <td ><span id="svapdxC1_1:dtServices:14:serviceName" class="outputText">Environmental Accesibility Adaptations</span></td> <td ></td> <td ></td> </tr> <tr ><td ><input id="svapdxC1_1:dtServices:15:serviceID" type="text" name="svapdxC1_1:dtServices:15:serviceID" value="223116" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1:dtServices:15:serviceType" class="outputText">Other Service</span></td> <td ><span id="svapdxC1_1:dtServices:15:serviceName" class="outputText">Home Delivered Meals</span></td> <td ></td> <td ></td> </tr> <tr ><td ><input id="svapdxC1_1:dtServices:16:serviceID" type="text" name="svapdxC1_1:dtServices:16:serviceID" value="223199" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1:dtServices:16:serviceType" class="outputText">Other Service</span></td> <td ><span id="svapdxC1_1:dtServices:16:serviceName" class="outputText">Mental Health Counseling</span></td> <td ></td> <td ></td> </tr> <tr ><td ><input id="svapdxC1_1:dtServices:17:serviceID" type="text" name="svapdxC1_1:dtServices:17:serviceID" value="223097" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1:dtServices:17:serviceType" class="outputText">Other Service</span></td> <td ><span id="svapdxC1_1:dtServices:17:serviceName" class="outputText">Personal Emergency Response Systems</span></td> <td ></td> <td ></td> </tr> <tr ><td ><input id="svapdxC1_1:dtServices:18:serviceID" type="text" name="svapdxC1_1:dtServices:18:serviceID" value="225399" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1:dtServices:18:serviceType" class="outputText">Other Service</span></td> <td ><span id="svapdxC1_1:dtServices:18:serviceName" class="outputText">Recovery Assistant</span></td> <td ></td> <td ></td> </tr> <tr ><td ><input id="svapdxC1_1:dtServices:19:serviceID" type="text" name="svapdxC1_1:dtServices:19:serviceID" value="223140" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1:dtServices:19:serviceType" class="outputText">Other Service</span></td> <td ><span id="svapdxC1_1:dtServices:19:serviceName" class="outputText">Transportation</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">Case Management</option> <option value="02">Homemaker</option> <option value="03">Home Health Aide</option> <option value="04">Personal Care</option> <option value="05" selected="selected">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"></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" selected="selected">17 Other Services</option> <option value="99"> </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="17010">17010 goods and services</option> <option value="17020">17020 interpreter</option> <option value="17030">17030 housing consultation</option> <option value="17990" selected="selected">17990 other</option> <option value="99"> </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">The service is provided 4 or more hours per day on a regularly scheduled basis for one or more days per week, or as specified in the service plan, in a non-institutional, community-based setting and shall encompass both health and social services needed to ensure the optimal functioning of the participant. Transportation to and from the center is included in the service definition and in the rate structure. Meals provided as part of these services shall not constitute a full nutritional regimen. Claims will denied by any Adult Day Health provider attempting to bill for transportation procedure codes. These procedure codes are not included on the Adult Day Health fee schedule and will deny as edits are built into the claim processing system to prevent duplicative transportation services for Adult Day Health from occurring. Services Covered and Limitations Payment for adult day services under the rate for a medical model is limited to providers that demonstrate to the department their ability to meet the following additional requirements: a program nurse shall be available on site for not less than fifty percent of each operating day; the program nurse shall be a registered nurse, except that a program nurse may be a licensed practical nurse if the program is located adjacent to a long term care facility licensed by the Department of Public Health, with ready access to a registered nurse from such long term care facility or the program nurse is supervised by a registered nurse who can be reached by telephone at any time during the operating day and who can be called to the center if needed within one half hour of the request. The program nurse is responsible for administering medications as needed and assuring that the participant's nursing services are coordinated with other services provided in the adult day health center, health and social services currently received at home or provided by existing community health agencies and personal physicians; additional personal care services shall be provided as specified in the individual plan of care, including but not limited to, bathing and transferring; ongoing training shall be available to the staff on a regular basis including, but not be limited to, orientation to key specialty areas such as physical therapy, occupational therapy, speech therapy and training in techniques for recognizing when to arrange or refer clients for such services; and individual therapeutic and rehabilitation services shall be coordinated by the center as specified in the individual plan of care including but not limited to, physical therapy, occupational therapy and speech therapy. The center shall have the capacity to provide such services on site; this requirement shall not preclude the provider of adult day health services from also arranging to provide therapeutic and rehabilitation services at other locations in order to meet needs of individual clients. Payment for adult day services shall include the costs of transportation, meals and all other required services except for individual therapeutic and rehabilitation services. For participants receiving assisted living services, adult day services are included as part of the monthly rate. A separate reimbursement for this service is not authorized. The assisted living service agency may arrange for adult day health services and reimburse the adult day service provider from their all- inclusive rate.</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">May be provided up to seven times per week.</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="223096" 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%;">Provider 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">Adult Day Health</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">Provider 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">Providers of Adult Day Health services shall: meet all applicable federal, state and local requirements including zoning, licensing, sanitation, fire and safety requirements; provide, at a minimum, nursing consultation services, social work services, nutritionally balanced meals to meet specialized dietary needs as prescribed by health care personnel, personal care services, recreational therapy and transportation services for individuals to and from their homes; provide adequate personnel to operate the program including: a full-time program administrator; nursing consultation during the full operating day by a Registered Nurse (RN) licensed in the state of Connecticut; and the direct care staff-to-participant ratio shall be a minimum of one to seven. Staffing shall be adequate to meet the needs of the client base. Volunteers shall be included in the ratio only when they conform to the same standards and requirements as paid staff. In order to be a provider of services to department clients, any facility located and operating within the state of Connecticut or located and operating outside the state of Connecticut, in a bordering state, shall be certified by the Connecticut Association of Adult Day Centers Incorporated, its successor agency or a department designee. A facility (center) located and operating outside the state of Connecticut in a bordering state shall be licensed or certified by its respective state and comply at all times with all pertinent licensure or certification requirements in addition to the approved standards for certification by the department. Certified facilities (centers) shall be in compliance with all applicable requirements in order to continue providing services to department clients. The failure to comply with any applicable requirements shall be grounds for the termination of its certification and participation as a department service provider.</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">Certification required by the Adult Day Care Association of CT. Certification is for 3 years.</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">n/a</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 Department's fiscal intermediary must ensure that the Day Care Program is certified by the association. The department maintains an ongoing list of certified Adult Day Programs and shares that information with the Access Agencies, other waiver personnel and Department social work staff who also might refer clients for the service.</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">Every two years</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" 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:1:svapdxC1_1a_prnt:lbl_STsvcName" for="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:STsvcName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:txt_lbl_STsvcName" class="outputText">Service:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:1:svapdxC1_1a_prnt:STsvcName" name="svapdxC1_1_prnt:dtServicesPrnt:1: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: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">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: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" selected="selected">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"> </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="01010" selected="selected">01010 case management</option> <option value="99"> </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">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 for monitoring 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. The Departments allows for a status review vist by the case manager when a waiver participant is in a hospital or nursing facility setting when the purpose of that visit is to reevaluate the total plan of care needs upon discharge back to the community based setting. This transitional care management service is provided one time in the first 45 days of a nursing home stay and/or one time only during a hospital stay. The reimbursement is based on a percentage of the rate for an initial assessment. 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. Crisis Intervention Efforts have two principle aims 1) Cushion the stressful event by immediate or emergency emotional or environmental first aid and 2) Strengthen the person in his or her coping through immediate therapeutic clarification and guidance during the crisis period. Examples of incidents that precipitate crisis interventions: suicide assessment, incidents of abuse, victimization, neglect, exploitation, imminent threat of homelessness. Service Brokerage and Advocacy requires that the Care Manager facilitate continual interaction between various segments of the service delivery system. When service breakdowns or requests for service changes occur, the Care Manager assists clients to ensure their rights to receive services based upon the person-centered model of care are upheld. Service brokerage and advocacy interventions include activities around finding and keeping providers for clients with difficult service needs, pre and post transitioning from an inpatient setting to the community, hospice and end of life care. Risk Management includes the identification of potential and perceived risks to the individual falling into four general categories; health, behavior, personal safety risks, and in-community risks. Managing these risks includes identification and documenting risks, developing written plans for addressing them, negotiating with clients the risks presented keeping client choice central to the process, and monitoring outcomes related to the risk. Client engagement refers to the process through which clients become active or involved in their care plans and participation in the program. The engagement process has several conceptualizations where interventions are designed to enhance client 1) receptivity, 2) expectancy 3) investment, 4) working relationship. 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.</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">Service may be billed on a per diem basis as long as the client remains in a community-based setting. Care management per diem may not be billed when a client is in an institutional setting. Prior authorization is required for a status review vist after the first 45 days of a nursing home stay.</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" 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" 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="223165" 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%;">Access Agency</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">Statutory Service</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">Care Management</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">Access Agency</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">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. 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: 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 empathetic 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> <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">The registered nurse shall hold a license to practice nursing in the State of CT. Care Managers are encouraged but not required to be certified as a long term care manager.</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">See above</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">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: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">Upon employment and as part of the Case Manager's annual performance appraisal.</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" 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:2:svapdxC1_1a_prnt:lbl_STsvcName" for="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:STsvcName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:txt_lbl_STsvcName" class="outputText">Service:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:STsvcName" name="svapdxC1_1_prnt:dtServicesPrnt:2:svapdxC1_1a_prnt:STsvcName" size="1" disabled="disabled"> <option value="00">Case Management</option> <option value="02" selected="selected">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: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:lblAlternateServiceTitle" class="outputText">Alternate Service Title (if any):</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"></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" selected="selected">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"> </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="08010">08010 home-based habilitation</option> <option value="08020">08020 home health aide</option> <option value="08030">08030 personal care</option> <option value="08040">08040 companion</option> <option value="08050" selected="selected">08050 homemaker</option> <option value="08060">08060 chore</option> <option value="99"> </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">Services consisting of general household activities (meal preparation, laundry and routine household care) provided by a trained homemaker, when the individual regularly responsible for these activities is temporarily absent or unable to manage the home and care for him or herself or others in the home. Homemakers shall meet such standards of education and training as are established by the State for the provision of these activities.</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" 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="223174" 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">Statutory 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">Homemaker</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">Certification required from the Department of Consumer Protection.</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"></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">The fiscal intermediary is responsible for verifying the certification prior to initiating enrollment of the agency.</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">Every 2 years</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:3:svapdxC1_1a_prnt:lbl_svcType" for="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:svcType" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:txt_lbl_svcType" class="outputText">Service Type:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:svcType" name="svapdxC1_1_prnt:dtServicesPrnt:3: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:3:svapdxC1_1a_prnt:lbl_STsvcName" for="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:STsvcName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:txt_lbl_STsvcName" class="outputText">Service:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:STsvcName" name="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:STsvcName" size="1" disabled="disabled"> <option value="00">Case Management</option> <option value="02">Homemaker</option> <option value="03">Home Health Aide</option> <option value="04" selected="selected">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:3:svapdxC1_1a_prnt:label1" for="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:svcAltName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:lblAlternateServiceTitle" class="outputText">Alternate Service Title (if any):</span></label> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:panel_svcAltName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:svcAltName" name="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:svcAltName" class="inputTextarea" readonly="readonly">Personal Care Assistant</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:3:svapdxC1_1a_prnt:lbl_svcTaxCat1" for="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:svcTaxCat1" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:txt_lbl_svcTaxCat1" class="outputText">Category 1:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:svcTaxCat1" name="svapdxC1_1_prnt:dtServicesPrnt:3: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" selected="selected">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"> </option> </select> </div> <div class="rightCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:lbl_svcTaxSubCat1" for="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:svcTaxSubCat1" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:txt_lbl_svcTaxSubCat1" class="outputText">Sub-Category 1:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:svcTaxSubCat1" name="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:svcTaxSubCat1" class="selectOneMenuLong" size="1" disabled="disabled"> <option value="08010">08010 home-based habilitation</option> <option value="08020">08020 home health aide</option> <option value="08030" selected="selected">08030 personal care</option> <option value="08040">08040 companion</option> <option value="08050">08050 homemaker</option> <option value="08060">08060 chore</option> <option value="99"> </option> </select> </div> </div> <div class="rowContact"> <div class="leftCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:lbl_taxCat2" for="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:svcTaxCat2" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:txt_lbl_taxCat2" class="outputText">Category 2:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:svcTaxCat2" name="svapdxC1_1_prnt:dtServicesPrnt:3: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:3:svapdxC1_1a_prnt:lbl_taxSubCat2" for="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:svcTaxSubCat2" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:txt_lbl_taxSubCat2" class="outputText">Sub-Category 2:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:svcTaxSubCat2" name="svapdxC1_1_prnt:dtServicesPrnt:3: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:3:svapdxC1_1a_prnt:lbl_taxCat3" for="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:svcTaxCat3" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:txt_lbl_taxCat3" class="outputText">Category 3:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:svcTaxCat3" name="svapdxC1_1_prnt:dtServicesPrnt:3: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:3:svapdxC1_1a_prnt:lbl_taxSubCat3" for="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:svcTaxSubCat3" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:txt_lbl_taxSubCat3" class="outputText">Sub-Category 3:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:svcTaxSubCat3" name="svapdxC1_1_prnt:dtServicesPrnt:3: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:3:svapdxC1_1a_prnt:lbl_taxCat4" for="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:svcTaxCat4" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:txt_lbl_taxCat4" class="outputText">Category 4:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:svcTaxCat4" name="svapdxC1_1_prnt:dtServicesPrnt:3: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:3:svapdxC1_1a_prnt:lbl_taxSubCat4" for="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:svcTaxSubCat4" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:txt_lbl_taxSubCat4" class="outputText">Sub-Category 4:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:svcTaxSubCat4" name="svapdxC1_1_prnt:dtServicesPrnt:3: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:3:svapdxC1_1a_prnt:lbl_svcDef" for="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:svcDef" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:lbl_txt_svcDef1" class="outputText">Service Definition</span><span id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:lbl_txt_svcDef2" class="outputTextNB em"> (Scope):</span></label> </div> <div></div> <div Class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:panel_svcDef"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:svcDef" name="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:svcDef" class="inputTextarea" readonly="readonly">One or more persons assisting an elder with tasks that the individual would typically do for him/herself in the absence of a disability. Such tasks may be performed at home or in the community. The participant has co-employer authority and is responsible to direct the activities of the PCA. Such services may include physical or verbal assistance to the consumer in accomplishing any Activity of Daily Living (ADL), or Instrumental Activities of Daily Living (IADL). ADL’s include bathing, dressing, toileting, transferring, and feeding. IADLs include meal preparation, shopping, housekeeping, laundry and cueing/reminders for self medication administration. Transportation costs associated with the provision of personal care outside of the participant's home is billed separately and is not included in the scope of personal care.</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:lbl_svcLimDscr" for="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:svcLimDscr" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:3: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:3:svapdxC1_1a_prnt:panel_svcLimDscr"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:svcLimDscr" name="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:svcLimDscr" class="inputTextarea" readonly="readonly">PCA services shall be cost effective on an individual basis when compared with Home Health Aide, Homemaker and Companion services. Recipients of PCA services will not be eligible to receive Homemaker or Companion services. Edits have been created in the MMIS to deny any Homemaker or Companion claims for PCA service recipients. Personal Care may not be provided to participants receiving Assisted Living Services as all of the functions of personal care are provided by the Assisted Living Service provider. The benefit plan for Assisted Living service recipients excludes personal care so that there could be no duplicative billing.</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:3:svapdxC1_1a_prnt:svcDelMthPtcDir" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:svcDelMthPtcDir" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:lbl_svcDelMthPtcDir" for="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:svcDelMthPtcDir" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:3: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:3:svapdxC1_1a_prnt:svcDelMthPvdrMgd" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:svcDelMthPvdrMgd" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:lbl_svcDelMthPvdrMgd" for="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:svcDelMthPvdrMgd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:3: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:3:svapdxC1_1a_prnt:svcPvdLegResp" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:svcPvdLegResp" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:lbl_svcPvdLegResp" for="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:svcPvdLegResp" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:txt_lbl_svcPvdLegResp" class="outputText">Legally Responsible Person</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:svcPvdRel" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:svcPvdRel" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:lbl_svcPvdRel" for="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:svcPvdRel" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:txt_lbl_svcPvdRel" class="outputText">Relative</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:svcPvdLegGrd" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:svcPvdLegGrd" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:lbl_svcPvdLegGrd" for="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:svcPvdLegGrd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:txt_lbl_svcPvdLegGrd" class="outputText">Legal Guardian</span></label> </div> </div> </div> <div class="pph"> <label id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:lbl_dtProviderTypes" for="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:dtProviderTypes" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:txt_lbl_dtProviderTypes" class="outputText">Provider Specifications:</span></label> </div> <table id="svapdxC1_1_prnt:dtServicesPrnt:3: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:3:svapdxC1_1a_prnt:dtProviderTypes:hdrProvCat" class="outputText">Provider Category</span></th><th scope="col" ><span id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:dtProviderTypes:hdrProvTyp" class="outputText">Provider Type Title</span></th></tr> </thead><tbody > <tr ><td ><input id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypeID" type="text" name="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypeID" value="226275" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypName" class="outputText">Agency</span></td> <td ><span id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:dtProviderTypes:0:pvdTypeName" class="outputText" style="width: 100%;">Provider Agency</span></td> </tr> </tbody> </table> <table id="svapdxC1_1_prnt:dtServicesPrnt:3: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:3:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceTypelbl" class="outputText">Service Type: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:3: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:3:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceNamelbl" class="outputText">Service Name: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceName" class="outputText">Personal Care Assistant</span> </div> </div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdCat" for="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdCat" class="outputText">Provider Category:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" name="svapdxC1_1_prnt:dtServicesPrnt:3: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:3:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdTypeName" for="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:3: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:3:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdTypeName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" name="svapdxC1_1_prnt:dtServicesPrnt:3: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:3: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:3:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualLic" for="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualLic1" class="outputText">License </span><span id="svapdxC1_1_prnt:dtServicesPrnt:3: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:3:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualLic"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" name="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" class="inputTextarea" readonly="readonly">If the provider agency is a Home Health Agency, it is required to be licensed in the state of Connecticut as specified in Subsection (k) section 19a-490 of the Connecticut General Statutes.</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualCert" for="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualCert1" class="outputText">Certificate </span><span id="svapdxC1_1_prnt:dtServicesPrnt:3: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:3:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualCert"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" name="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" class="inputTextarea" readonly="readonly">If the provider is a Homemaker/Companion Agency, it must be registered with the Department of Consumer Protection.</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualOthStd" for="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualOthStd1" class="outputText">Other Standard </span><span id="svapdxC1_1_prnt:dtServicesPrnt:3: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:3:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualOthStd"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" name="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" class="inputTextarea" readonly="readonly">The PCA hired by the agency shall meet all of the same qualifications as an individual PCA as follows: • Be at least 18 years of age • Have experience doing personal care • Be able to follow written or verbal instructions given by the consumer or the consumer’'s conservator • Be physically able to perform the services required • Follow instructions given by the consumer or the consumer'’s conservator • Receive instruction/training from consumer or their designee concerning all personal care services delineated in the service plan • Be able to handle emergencies • Demonstrate the ability to implement cognitive behavioral interventions/take direction to carry out the plan.</textarea></span> </div> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:3: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:3:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdVrfEnt" for="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:3: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:3:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdVrfEnt"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" name="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" class="inputTextarea" readonly="readonly">Agency and fiscal intermediary</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdVrfFreq" for="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:3: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:3:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdVrfFreq"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" name="svapdxC1_1_prnt:dtServicesPrnt:3:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" class="inputTextarea" readonly="readonly">At the time of enrollment and every two 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> </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:4:svapdxC1_1a_prnt:lbl_svcType" for="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:svcType" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:txt_lbl_svcType" class="outputText">Service Type:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:svcType" name="svapdxC1_1_prnt:dtServicesPrnt:4: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:4:svapdxC1_1a_prnt:lbl_STsvcName" for="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:STsvcName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:txt_lbl_STsvcName" class="outputText">Service:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:STsvcName" name="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:STsvcName" size="1" disabled="disabled"> <option value="00">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" selected="selected">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:4:svapdxC1_1a_prnt:label1" for="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:svcAltName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:lblAlternateServiceTitle" class="outputText">Alternate Service Title (if any):</span></label> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:panel_svcAltName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:svcAltName" name="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:svcAltName" class="inputTextarea" readonly="readonly"></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:4:svapdxC1_1a_prnt:lbl_svcTaxCat1" for="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:svcTaxCat1" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:txt_lbl_svcTaxCat1" class="outputText">Category 1:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:svcTaxCat1" name="svapdxC1_1_prnt:dtServicesPrnt:4: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" selected="selected">17 Other Services</option> <option value="99"> </option> </select> </div> <div class="rightCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:lbl_svcTaxSubCat1" for="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:svcTaxSubCat1" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:txt_lbl_svcTaxSubCat1" class="outputText">Sub-Category 1:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:svcTaxSubCat1" name="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:svcTaxSubCat1" class="selectOneMenuLong" size="1" disabled="disabled"> <option value="17010">17010 goods and services</option> <option value="17020">17020 interpreter</option> <option value="17030">17030 housing consultation</option> <option value="17990" selected="selected">17990 other</option> <option value="99"> </option> </select> </div> </div> <div class="rowContact"> <div class="leftCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:lbl_taxCat2" for="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:svcTaxCat2" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:txt_lbl_taxCat2" class="outputText">Category 2:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:svcTaxCat2" name="svapdxC1_1_prnt:dtServicesPrnt:4: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:4:svapdxC1_1a_prnt:lbl_taxSubCat2" for="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:svcTaxSubCat2" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:txt_lbl_taxSubCat2" class="outputText">Sub-Category 2:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:svcTaxSubCat2" name="svapdxC1_1_prnt:dtServicesPrnt:4: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:4:svapdxC1_1a_prnt:lbl_taxCat3" for="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:svcTaxCat3" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:txt_lbl_taxCat3" class="outputText">Category 3:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:svcTaxCat3" name="svapdxC1_1_prnt:dtServicesPrnt:4: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:4:svapdxC1_1a_prnt:lbl_taxSubCat3" for="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:svcTaxSubCat3" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:txt_lbl_taxSubCat3" class="outputText">Sub-Category 3:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:svcTaxSubCat3" name="svapdxC1_1_prnt:dtServicesPrnt:4: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:4:svapdxC1_1a_prnt:lbl_taxCat4" for="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:svcTaxCat4" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:txt_lbl_taxCat4" class="outputText">Category 4:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:svcTaxCat4" name="svapdxC1_1_prnt:dtServicesPrnt:4: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:4:svapdxC1_1a_prnt:lbl_taxSubCat4" for="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:svcTaxSubCat4" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:txt_lbl_taxSubCat4" class="outputText">Sub-Category 4:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:svcTaxSubCat4" name="svapdxC1_1_prnt:dtServicesPrnt:4: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:4:svapdxC1_1a_prnt:lbl_svcDef" for="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:svcDef" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:lbl_txt_svcDef1" class="outputText">Service Definition</span><span id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:lbl_txt_svcDef2" class="outputTextNB em"> (Scope):</span></label> </div> <div></div> <div Class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:panel_svcDef"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:svcDef" name="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:svcDef" class="inputTextarea" readonly="readonly">Services provided to individuals unable to care for themselves; furnished on a short-term basis because of the absence or need for relief of those persons normally providing the care. In home respite providers shall include but are not limited to homemakers, companions or Home Health aides. Services may be provided in the home or outside of the home including but not limited to a licensed or certified facility such as a Rest Home with Nursing Supervision or Chronic and Convalescent Nursing Home. Federal financial participation is not claimed for the cost of room and board except when provided as part of respite care furnished in a facility approved by the State that is not a private residence.</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:lbl_svcLimDscr" for="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:svcLimDscr" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:4: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:4:svapdxC1_1a_prnt:panel_svcLimDscr"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:svcLimDscr" name="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:svcLimDscr" class="inputTextarea" readonly="readonly">Respite services provided in a licensed facility are limited to 30 days per calendar year per recipient. In home respite services are limited to 720 hours per year per recipient.</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:4:svapdxC1_1a_prnt:svcDelMthPtcDir" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:svcDelMthPtcDir" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:lbl_svcDelMthPtcDir" for="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:svcDelMthPtcDir" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:4: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:4:svapdxC1_1a_prnt:svcDelMthPvdrMgd" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:svcDelMthPvdrMgd" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:lbl_svcDelMthPvdrMgd" for="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:svcDelMthPvdrMgd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:4: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:4:svapdxC1_1a_prnt:svcPvdLegResp" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:svcPvdLegResp" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:lbl_svcPvdLegResp" for="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:svcPvdLegResp" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:txt_lbl_svcPvdLegResp" class="outputText">Legally Responsible Person</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:svcPvdRel" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:svcPvdRel" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:lbl_svcPvdRel" for="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:svcPvdRel" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:txt_lbl_svcPvdRel" class="outputText">Relative</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:svcPvdLegGrd" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:svcPvdLegGrd" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:lbl_svcPvdLegGrd" for="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:svcPvdLegGrd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:txt_lbl_svcPvdLegGrd" class="outputText">Legal Guardian</span></label> </div> </div> </div> <div class="pph"> <label id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:lbl_dtProviderTypes" for="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypes" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:txt_lbl_dtProviderTypes" class="outputText">Provider Specifications:</span></label> </div> <table id="svapdxC1_1_prnt:dtServicesPrnt:4: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:4:svapdxC1_1a_prnt:dtProviderTypes:hdrProvCat" class="outputText">Provider Category</span></th><th scope="col" ><span id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypes:hdrProvTyp" class="outputText">Provider Type Title</span></th></tr> </thead><tbody > <tr ><td ><input id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypeID" type="text" name="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypeID" value="223235" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypName" class="outputText">Agency</span></td> <td ><span id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypes:0:pvdTypeName" class="outputText" style="width: 100%;">Chronic and Convalescent Nursing Homes/Rest Homes with Nursing Supervision</span></td> </tr> <tr ><td ><input id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypes:1:providerTypeID" type="text" name="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypes:1:providerTypeID" value="223234" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypes:1:providerTypName" class="outputText">Agency</span></td> <td ><span id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypes:1:pvdTypeName" class="outputText" style="width: 100%;">Provider agencies of waiver services such as Homemaker/Companion Agencies or Home Health Agencies</span></td> </tr> </tbody> </table> <table id="svapdxC1_1_prnt:dtServicesPrnt:4: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:4:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceTypelbl" class="outputText">Service Type: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:4: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:4:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceNamelbl" class="outputText">Service Name: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceName" class="outputText">Respite</span> </div> </div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdCat" for="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdCat" class="outputText">Provider Category:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" name="svapdxC1_1_prnt:dtServicesPrnt:4: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:4:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdTypeName" for="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:4: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:4:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdTypeName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" name="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" class="inputTextarea" readonly="readonly">Chronic and Convalescent Nursing Homes/Rest Homes with Nursing Supervision</textarea></span> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:4: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:4:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualLic" for="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualLic1" class="outputText">License </span><span id="svapdxC1_1_prnt:dtServicesPrnt:4: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:4:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualLic"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" name="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" class="inputTextarea" readonly="readonly">For respite in a facility, either Rest Home with Nursing Supervision or Chronic and Convalescent Nursing Home, facilities must be licensed by the CT Department of Public Health.</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualCert" for="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualCert1" class="outputText">Certificate </span><span id="svapdxC1_1_prnt:dtServicesPrnt:4: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:4:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualCert"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" name="svapdxC1_1_prnt:dtServicesPrnt:4: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:4:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualOthStd" for="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualOthStd1" class="outputText">Other Standard </span><span id="svapdxC1_1_prnt:dtServicesPrnt:4: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:4:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualOthStd"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" name="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" class="inputTextarea" readonly="readonly"></textarea></span> </div> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:4: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:4:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdVrfEnt" for="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:4: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:4:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdVrfEnt"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" name="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" class="inputTextarea" readonly="readonly">CT Department of Public Health</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdVrfFreq" for="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:4: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:4:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdVrfFreq"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" name="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" class="inputTextarea" readonly="readonly">Every two years</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:4:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_serviceTypelbl" class="outputText">Service Type: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_serviceType" class="outputText">Statutory Service</span> </div> <div class="firstIndent"> <span id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_serviceNamelbl" class="outputText">Service Name: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_serviceName" class="outputText">Respite</span> </div> </div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdCat" for="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdCat" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_lbl_pvdCat" class="outputText">Provider Category:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdCat" name="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:1: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:4:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdTypeName" for="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdTypeName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:4: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:4:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:panel_pvdTypeName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdTypeName" name="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdTypeName" class="inputTextarea" readonly="readonly">Provider agencies of waiver services such as Homemaker/Companion Agencies or Home Health Agencies</textarea></span> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:4: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:4:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdQualLic" for="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualLic" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_lbl_pvdQualLic1" class="outputText">License </span><span id="svapdxC1_1_prnt:dtServicesPrnt:4: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:4:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:panel_pvdQualLic"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualLic" name="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualLic" class="inputTextarea" readonly="readonly">Licensing is not applicable to Homemakers and Companions, however all requirements of a Homemaker/Companion Agency are applicable when providing respite services. Home Health Agencies must be licensed by the CT Department of Public Health.</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdQualCert" for="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualCert" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_lbl_pvdQualCert1" class="outputText">Certificate </span><span id="svapdxC1_1_prnt:dtServicesPrnt:4: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:4:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:panel_pvdQualCert"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualCert" name="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualCert" class="inputTextarea" readonly="readonly">N/A</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdQualOthStd" for="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualOthStd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_lbl_pvdQualOthStd1" class="outputText">Other Standard </span><span id="svapdxC1_1_prnt:dtServicesPrnt:4: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:4:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:panel_pvdQualOthStd"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualOthStd" name="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualOthStd" class="inputTextarea" readonly="readonly"></textarea></span> </div> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:4: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:4:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdVrfEnt" for="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdVrfEnt" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:4: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:4:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:panel_pvdVrfEnt"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdVrfEnt" name="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdVrfEnt" class="inputTextarea" readonly="readonly">Fiscal Intermediary for in home respite and CT Department of Public Health for facilities and Home Health Care Agencies.</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdVrfFreq" for="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdVrfFreq" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:4: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:4:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:panel_pvdVrfFreq"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdVrfFreq" name="svapdxC1_1_prnt:dtServicesPrnt:4:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdVrfFreq" class="inputTextarea" readonly="readonly">Every 2 years</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:5:svapdxC1_1a_prnt:lbl_svcType" for="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:svcType" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:txt_lbl_svcType" class="outputText">Service Type:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:svcType" name="svapdxC1_1_prnt:dtServicesPrnt:5: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:5:svapdxC1_1a_prnt:lbl_PDsvcName" for="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:PDsvcName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:txt_lbl_PDsvcName" class="outputText">Support for Participant Direction:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:PDsvcName" name="svapdxC1_1_prnt:dtServicesPrnt:5: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:5:svapdxC1_1a_prnt:label1" for="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:svcAltName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:lblAlternateServiceTitle" class="outputText">Alternate Service Title (if any):</span></label> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:panel_svcAltName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:svcAltName" name="svapdxC1_1_prnt:dtServicesPrnt:5: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:5:svapdxC1_1a_prnt:lbl_svcTaxCat1" for="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:svcTaxCat1" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:txt_lbl_svcTaxCat1" class="outputText">Category 1:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:svcTaxCat1" name="svapdxC1_1_prnt:dtServicesPrnt:5: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" selected="selected">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"> </option> </select> </div> <div class="rightCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:lbl_svcTaxSubCat1" for="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:svcTaxSubCat1" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:txt_lbl_svcTaxSubCat1" class="outputText">Sub-Category 1:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:svcTaxSubCat1" name="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:svcTaxSubCat1" class="selectOneMenuLong" size="1" disabled="disabled"> <option value="12010">12010 financial management services in support of self-direction</option> <option value="12020" selected="selected">12020 information and assistance in support of self-direction</option> <option value="99"> </option> </select> </div> </div> <div class="rowContact"> <div class="leftCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:lbl_taxCat2" for="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:svcTaxCat2" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:txt_lbl_taxCat2" class="outputText">Category 2:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:svcTaxCat2" name="svapdxC1_1_prnt:dtServicesPrnt:5: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:5:svapdxC1_1a_prnt:lbl_taxSubCat2" for="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:svcTaxSubCat2" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:txt_lbl_taxSubCat2" class="outputText">Sub-Category 2:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:svcTaxSubCat2" name="svapdxC1_1_prnt:dtServicesPrnt:5: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:5:svapdxC1_1a_prnt:lbl_taxCat3" for="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:svcTaxCat3" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:txt_lbl_taxCat3" class="outputText">Category 3:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:svcTaxCat3" name="svapdxC1_1_prnt:dtServicesPrnt:5: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:5:svapdxC1_1a_prnt:lbl_taxSubCat3" for="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:svcTaxSubCat3" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:txt_lbl_taxSubCat3" class="outputText">Sub-Category 3:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:svcTaxSubCat3" name="svapdxC1_1_prnt:dtServicesPrnt:5: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:5:svapdxC1_1a_prnt:lbl_taxCat4" for="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:svcTaxCat4" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:txt_lbl_taxCat4" class="outputText">Category 4:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:svcTaxCat4" name="svapdxC1_1_prnt:dtServicesPrnt:5: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:5:svapdxC1_1a_prnt:lbl_taxSubCat4" for="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:svcTaxSubCat4" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:txt_lbl_taxSubCat4" class="outputText">Sub-Category 4:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:svcTaxSubCat4" name="svapdxC1_1_prnt:dtServicesPrnt:5: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:5:svapdxC1_1a_prnt:lbl_svcDef" for="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:svcDef" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:lbl_txt_svcDef1" class="outputText">Service Definition</span><span id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:lbl_txt_svcDef2" class="outputTextNB em"> (Scope):</span></label> </div> <div></div> <div Class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:panel_svcDef"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:svcDef" name="svapdxC1_1_prnt:dtServicesPrnt:5: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.</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:lbl_svcLimDscr" for="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:svcLimDscr" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:5: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:5:svapdxC1_1a_prnt:panel_svcLimDscr"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:svcLimDscr" name="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:svcLimDscr" class="inputTextarea" readonly="readonly">Service is limited to those who direct their own supports. Maximum Allocation is 10% of the consumer's PCA Waiver Service Budget. Service is available after participant has exhausted the $500 annual benefit available under the Community First Choice state plan option.</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:5:svapdxC1_1a_prnt:svcDelMthPtcDir" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:svcDelMthPtcDir" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:lbl_svcDelMthPtcDir" for="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:svcDelMthPtcDir" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:5: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:5:svapdxC1_1a_prnt:svcDelMthPvdrMgd" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:svcDelMthPvdrMgd" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:lbl_svcDelMthPvdrMgd" for="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:svcDelMthPvdrMgd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:5: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:5:svapdxC1_1a_prnt:svcPvdLegResp" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:svcPvdLegResp" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:lbl_svcPvdLegResp" for="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:svcPvdLegResp" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:txt_lbl_svcPvdLegResp" class="outputText">Legally Responsible Person</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:svcPvdRel" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:svcPvdRel" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:lbl_svcPvdRel" for="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:svcPvdRel" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:txt_lbl_svcPvdRel" class="outputText">Relative</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:svcPvdLegGrd" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:svcPvdLegGrd" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:lbl_svcPvdLegGrd" for="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:svcPvdLegGrd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:txt_lbl_svcPvdLegGrd" class="outputText">Legal Guardian</span></label> </div> </div> </div> <div class="pph"> <label id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:lbl_dtProviderTypes" for="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypes" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:txt_lbl_dtProviderTypes" class="outputText">Provider Specifications:</span></label> </div> <table id="svapdxC1_1_prnt:dtServicesPrnt:5: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:5:svapdxC1_1a_prnt:dtProviderTypes:hdrProvCat" class="outputText">Provider Category</span></th><th scope="col" ><span id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypes:hdrProvTyp" class="outputText">Provider Type Title</span></th></tr> </thead><tbody > <tr ><td ><input id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypeID" type="text" name="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypeID" value="225555" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypName" class="outputText">Agency</span></td> <td ><span id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypes:0:pvdTypeName" class="outputText" style="width: 100%;">Agency Provider</span></td> </tr> <tr ><td ><input id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypes:1:providerTypeID" type="text" name="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypes:1:providerTypeID" value="225554" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypes:1:providerTypName" class="outputText">Individual</span></td> <td ><span id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypes:1:pvdTypeName" class="outputText" style="width: 100%;">Individual Provider</span></td> </tr> </tbody> </table> <table id="svapdxC1_1_prnt:dtServicesPrnt:5: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:5:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceTypelbl" class="outputText">Service Type: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:5: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:5:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceNamelbl" class="outputText">Service Name: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:5: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:5:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdCat" for="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdCat" class="outputText">Provider Category:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" name="svapdxC1_1_prnt:dtServicesPrnt:5: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:5:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdTypeName" for="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:5: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:5:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdTypeName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" name="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" class="inputTextarea" readonly="readonly">Agency Provider</textarea></span> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:5: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:5:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualLic" for="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualLic1" class="outputText">License </span><span id="svapdxC1_1_prnt:dtServicesPrnt:5: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:5:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualLic"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" name="svapdxC1_1_prnt:dtServicesPrnt:5: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:5:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualCert" for="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualCert1" class="outputText">Certificate </span><span id="svapdxC1_1_prnt:dtServicesPrnt:5: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:5:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualCert"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" name="svapdxC1_1_prnt:dtServicesPrnt:5: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:5:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualOthStd" for="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualOthStd1" class="outputText">Other Standard </span><span id="svapdxC1_1_prnt:dtServicesPrnt:5: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:5:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualOthStd"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" name="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" class="inputTextarea" readonly="readonly">The FI will verify that employees meet the following qualifications prior to enrollment: - 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:5: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:5:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdVrfEnt" for="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:5: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:5:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdVrfEnt"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" name="svapdxC1_1_prnt:dtServicesPrnt:5: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:5:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdVrfFreq" for="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:5: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:5:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdVrfFreq"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" name="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" class="inputTextarea" readonly="readonly">Prior to enrollment and every two 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:5:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_serviceTypelbl" class="outputText">Service Type: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:5: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:5:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_serviceNamelbl" class="outputText">Service Name: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:5: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:5:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdCat" for="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdCat" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_lbl_pvdCat" class="outputText">Provider Category:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdCat" name="svapdxC1_1_prnt:dtServicesPrnt:5: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:5:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdTypeName" for="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdTypeName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:5: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:5:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:panel_pvdTypeName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdTypeName" name="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdTypeName" class="inputTextarea" readonly="readonly">Individual Provider</textarea></span> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:5: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:5:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdQualLic" for="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualLic" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_lbl_pvdQualLic1" class="outputText">License </span><span id="svapdxC1_1_prnt:dtServicesPrnt:5: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:5:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:panel_pvdQualLic"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualLic" name="svapdxC1_1_prnt:dtServicesPrnt:5: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:5:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdQualCert" for="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualCert" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_lbl_pvdQualCert1" class="outputText">Certificate </span><span id="svapdxC1_1_prnt:dtServicesPrnt:5: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:5:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:panel_pvdQualCert"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualCert" name="svapdxC1_1_prnt:dtServicesPrnt:5: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:5:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdQualOthStd" for="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualOthStd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_lbl_pvdQualOthStd1" class="outputText">Other Standard </span><span id="svapdxC1_1_prnt:dtServicesPrnt:5: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:5:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:panel_pvdQualOthStd"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualOthStd" name="svapdxC1_1_prnt:dtServicesPrnt:5: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 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:5: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:5:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdVrfEnt" for="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdVrfEnt" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:5: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:5:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:panel_pvdVrfEnt"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdVrfEnt" name="svapdxC1_1_prnt:dtServicesPrnt:5: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:5:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdVrfFreq" for="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdVrfFreq" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:5: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:5:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:panel_pvdVrfFreq"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdVrfFreq" name="svapdxC1_1_prnt:dtServicesPrnt:5:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdVrfFreq" class="inputTextarea" readonly="readonly">Prior to starting employment and every two years thereafter. OIG checks are done monthly</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:6:svapdxC1_1a_prnt:lbl_svcType" for="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:svcType" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:txt_lbl_svcType" class="outputText">Service Type:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:svcType" name="svapdxC1_1_prnt:dtServicesPrnt:6: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:6:svapdxC1_1a_prnt:label1" for="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:svcAltName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:lblUserServiceTitle" class="outputText">Service Title:</span></label> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:panel_svcAltName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:svcAltName" name="svapdxC1_1_prnt:dtServicesPrnt:6: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:6:svapdxC1_1a_prnt:lbl_svcTaxCat1" for="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:svcTaxCat1" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:txt_lbl_svcTaxCat1" class="outputText">Category 1:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:svcTaxCat1" name="svapdxC1_1_prnt:dtServicesPrnt:6: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" selected="selected">17 Other Services</option> <option value="99"> </option> </select> </div> <div class="rightCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:lbl_svcTaxSubCat1" for="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:svcTaxSubCat1" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:txt_lbl_svcTaxSubCat1" class="outputText">Sub-Category 1:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:svcTaxSubCat1" name="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:svcTaxSubCat1" class="selectOneMenuLong" size="1" disabled="disabled"> <option value="17010">17010 goods and services</option> <option value="17020">17020 interpreter</option> <option value="17030">17030 housing consultation</option> <option value="17990" selected="selected">17990 other</option> <option value="99"> </option> </select> </div> </div> <div class="rowContact"> <div class="leftCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:lbl_taxCat2" for="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:svcTaxCat2" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:txt_lbl_taxCat2" class="outputText">Category 2:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:svcTaxCat2" name="svapdxC1_1_prnt:dtServicesPrnt:6: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:6:svapdxC1_1a_prnt:lbl_taxSubCat2" for="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:svcTaxSubCat2" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:txt_lbl_taxSubCat2" class="outputText">Sub-Category 2:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:svcTaxSubCat2" name="svapdxC1_1_prnt:dtServicesPrnt:6: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:6:svapdxC1_1a_prnt:lbl_taxCat3" for="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:svcTaxCat3" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:txt_lbl_taxCat3" class="outputText">Category 3:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:svcTaxCat3" name="svapdxC1_1_prnt:dtServicesPrnt:6: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:6:svapdxC1_1a_prnt:lbl_taxSubCat3" for="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:svcTaxSubCat3" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:txt_lbl_taxSubCat3" class="outputText">Sub-Category 3:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:svcTaxSubCat3" name="svapdxC1_1_prnt:dtServicesPrnt:6: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:6:svapdxC1_1a_prnt:lbl_taxCat4" for="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:svcTaxCat4" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:txt_lbl_taxCat4" class="outputText">Category 4:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:svcTaxCat4" name="svapdxC1_1_prnt:dtServicesPrnt:6: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:6:svapdxC1_1a_prnt:lbl_taxSubCat4" for="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:svcTaxSubCat4" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:txt_lbl_taxSubCat4" class="outputText">Sub-Category 4:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:svcTaxSubCat4" name="svapdxC1_1_prnt:dtServicesPrnt:6: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:6:svapdxC1_1a_prnt:lbl_svcDef" for="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:svcDef" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:lbl_txt_svcDef1" class="outputText">Service Definition</span><span id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:lbl_txt_svcDef2" class="outputTextNB em"> (Scope):</span></label> </div> <div></div> <div Class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:panel_svcDef"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:svcDef" name="svapdxC1_1_prnt:dtServicesPrnt:6: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 3 participants in a home. The Adult Family Living/Foster Care provider may not administer medication but may supervise the participant&#8217;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:6:svapdxC1_1a_prnt:lbl_svcLimDscr" for="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:svcLimDscr" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:6: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:6:svapdxC1_1a_prnt:panel_svcLimDscr"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:svcLimDscr" name="svapdxC1_1_prnt:dtServicesPrnt:6: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:6:svapdxC1_1a_prnt:svcDelMthPtcDir" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:svcDelMthPtcDir" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:lbl_svcDelMthPtcDir" for="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:svcDelMthPtcDir" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:6: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:6:svapdxC1_1a_prnt:svcDelMthPvdrMgd" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:svcDelMthPvdrMgd" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:lbl_svcDelMthPvdrMgd" for="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:svcDelMthPvdrMgd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:6: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:6:svapdxC1_1a_prnt:svcPvdLegResp" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:svcPvdLegResp" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:lbl_svcPvdLegResp" for="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:svcPvdLegResp" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:txt_lbl_svcPvdLegResp" class="outputText">Legally Responsible Person</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:svcPvdRel" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:svcPvdRel" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:lbl_svcPvdRel" for="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:svcPvdRel" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:txt_lbl_svcPvdRel" class="outputText">Relative</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:svcPvdLegGrd" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:svcPvdLegGrd" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:lbl_svcPvdLegGrd" for="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:svcPvdLegGrd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:txt_lbl_svcPvdLegGrd" class="outputText">Legal Guardian</span></label> </div> </div> </div> <div class="pph"> <label id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:lbl_dtProviderTypes" for="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:dtProviderTypes" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:txt_lbl_dtProviderTypes" class="outputText">Provider Specifications:</span></label> </div> <table id="svapdxC1_1_prnt:dtServicesPrnt:6: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:6:svapdxC1_1a_prnt:dtProviderTypes:hdrProvCat" class="outputText">Provider Category</span></th><th scope="col" ><span id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:dtProviderTypes:hdrProvTyp" class="outputText">Provider Type Title</span></th></tr> </thead><tbody > <tr ><td ><input id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypeID" type="text" name="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypeID" value="223228" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypName" class="outputText">Agency</span></td> <td ><span id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:dtProviderTypes:0:pvdTypeName" class="outputText" style="width: 100%;">Provider Agency</span></td> </tr> </tbody> </table> <table id="svapdxC1_1_prnt:dtServicesPrnt:6: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:6:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceTypelbl" class="outputText">Service Type: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:6: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:6:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceNamelbl" class="outputText">Service Name: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:6: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:6:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdCat" for="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdCat" class="outputText">Provider Category:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" name="svapdxC1_1_prnt:dtServicesPrnt:6: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:6:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdTypeName" for="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:6: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:6:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdTypeName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" name="svapdxC1_1_prnt:dtServicesPrnt:6: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:6: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:6:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualLic" for="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualLic1" class="outputText">License </span><span id="svapdxC1_1_prnt:dtServicesPrnt:6: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:6:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualLic"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" name="svapdxC1_1_prnt:dtServicesPrnt:6: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:6:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualCert" for="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualCert1" class="outputText">Certificate </span><span id="svapdxC1_1_prnt:dtServicesPrnt:6: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:6:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualCert"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" name="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" class="inputTextarea" readonly="readonly">N/A</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualOthStd" for="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualOthStd1" class="outputText">Other Standard </span><span id="svapdxC1_1_prnt:dtServicesPrnt:6: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:6:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualOthStd"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" name="svapdxC1_1_prnt:dtServicesPrnt:6: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 must be 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 year of age, be 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 homes meet 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:6: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:6:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdVrfEnt" for="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:6: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:6:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdVrfEnt"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" name="svapdxC1_1_prnt:dtServicesPrnt:6: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:6:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdVrfFreq" for="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:6: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:6:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdVrfFreq"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" name="svapdxC1_1_prnt:dtServicesPrnt:6:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" class="inputTextarea" readonly="readonly">Upon enrollment and bi-annually 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> <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:7:svapdxC1_1a_prnt:lbl_svcType" for="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:svcType" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:txt_lbl_svcType" class="outputText">Service Type:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:svcType" name="svapdxC1_1_prnt:dtServicesPrnt:7: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:7:svapdxC1_1a_prnt:label1" for="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:svcAltName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:lblUserServiceTitle" class="outputText">Service Title:</span></label> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:panel_svcAltName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:svcAltName" name="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:svcAltName" class="inputTextarea" readonly="readonly">Assisted Living</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:7:svapdxC1_1a_prnt:lbl_svcTaxCat1" for="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:svcTaxCat1" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:txt_lbl_svcTaxCat1" class="outputText">Category 1:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:svcTaxCat1" name="svapdxC1_1_prnt:dtServicesPrnt:7: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" selected="selected">17 Other Services</option> <option value="99"> </option> </select> </div> <div class="rightCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:lbl_svcTaxSubCat1" for="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:svcTaxSubCat1" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:txt_lbl_svcTaxSubCat1" class="outputText">Sub-Category 1:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:svcTaxSubCat1" name="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:svcTaxSubCat1" class="selectOneMenuLong" size="1" disabled="disabled"> <option value="17010">17010 goods and services</option> <option value="17020">17020 interpreter</option> <option value="17030">17030 housing consultation</option> <option value="17990" selected="selected">17990 other</option> <option value="99"> </option> </select> </div> </div> <div class="rowContact"> <div class="leftCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:lbl_taxCat2" for="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:svcTaxCat2" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:txt_lbl_taxCat2" class="outputText">Category 2:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:svcTaxCat2" name="svapdxC1_1_prnt:dtServicesPrnt:7: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:7:svapdxC1_1a_prnt:lbl_taxSubCat2" for="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:svcTaxSubCat2" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:txt_lbl_taxSubCat2" class="outputText">Sub-Category 2:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:svcTaxSubCat2" name="svapdxC1_1_prnt:dtServicesPrnt:7: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:7:svapdxC1_1a_prnt:lbl_taxCat3" for="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:svcTaxCat3" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:txt_lbl_taxCat3" class="outputText">Category 3:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:svcTaxCat3" name="svapdxC1_1_prnt:dtServicesPrnt:7: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:7:svapdxC1_1a_prnt:lbl_taxSubCat3" for="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:svcTaxSubCat3" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:txt_lbl_taxSubCat3" class="outputText">Sub-Category 3:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:svcTaxSubCat3" name="svapdxC1_1_prnt:dtServicesPrnt:7: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:7:svapdxC1_1a_prnt:lbl_taxCat4" for="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:svcTaxCat4" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:txt_lbl_taxCat4" class="outputText">Category 4:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:svcTaxCat4" name="svapdxC1_1_prnt:dtServicesPrnt:7: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:7:svapdxC1_1a_prnt:lbl_taxSubCat4" for="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:svcTaxSubCat4" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:txt_lbl_taxSubCat4" class="outputText">Sub-Category 4:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:svcTaxSubCat4" name="svapdxC1_1_prnt:dtServicesPrnt:7: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:7:svapdxC1_1a_prnt:lbl_svcDef" for="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:svcDef" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:lbl_txt_svcDef1" class="outputText">Service Definition</span><span id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:lbl_txt_svcDef2" class="outputTextNB em"> (Scope):</span></label> </div> <div></div> <div Class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:panel_svcDef"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:svcDef" name="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:svcDef" class="inputTextarea" readonly="readonly">Personal care and services, homemaker, chore, attendant care, companion services, medication oversight, therapeutic social and recreational programming provided in a home-like environment in a Managed Residential Community, in conjunction with residing in the community. A managed residential community is a living arrangement consisting of private residential units that provides a managed group living environment including housing and services. A private residential unit means a living arrangement rented by the participant that includes a private full bath within the unit and facilities and equipment for the preparation and storage of food. This service includes 24 hour on-site response staff to meet scheduled or unpredictable needs in a way that promotes maximum dignity and independence, and to provide supervision, safety and security. Other individuals or agencies may also furnish care directly, or under arrangement with the Managed Residential Community, but the care provided by these other entities supplements that provided by the community care facility and does not supplant it. Mental health counseling and the Personal Emergency Response System are services available to assisted living clients. Nursing and skilled therapy services are incidental rather than integral to the provision of assisted living services. Payment is not made for 24 hour skilled care. Federal financial participation is not available for room and board, items of comfort or convenience, or the costs of facility maintenance, upkeep and improvement. The methodology by which the costs of room and board are excluded from payments for assisted living services is described in Appendix I-5. Personalized care is furnished to individuals who reside in their own living units (which may include dually occupied units when both occupants consent to the arrangement) which includes kitchenette and living rooms and which contain bedrooms and toilet facilities. The consumer has a right to privacy. Living units may be locked at the discretion of the consumer, except when a physician or mental health professional has certified in writing that the consumer is sufficiently cognitively impaired as to be a danger to self or others if given the opportunity to lock the door. Each living unit is separate and distinct from each other. The communities have a central dining room, living room or parlor, and common activity center(s)(which may also serve as living rooms or dining rooms). The consumer retains the right to assume risk, tempered only by the individual's ability to assume responsibility for that risk. Care must be furnished in a way which fosters the independence of each consumer. Routines of care provision and service delivery must be consumer-driven to the maximum extent possible, and treat each person with dignity and respect. Care plans will be developed based on the individual's service needs. There are four levels of service provided in assisted living facilities based on the consumer's combined needs for personal care and nursing services. The four levels are occasional which is 1-3.75 hours per week of service, limited which is 4-8.75 hours per week of service, moderate which is 9-14.75 hours per week of service and extensive which is 15-25 hours per week of service. Level of service assigned depends upon the volume and extent of services needed by each individual and is not a limitation of service. Assisted Living services are provided under the waiver statewide in Private Assisted Living Facilities under CGS 17b-365 and in 17 state funded congregate and 4 HUD facilities under CGS 8-206e(e). Additionally, Assisted Living Services are provided in 4 demonstration sites under 19-13-D105 of the regulations of CT state agencies.</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:lbl_svcLimDscr" for="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:svcLimDscr" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:7: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:7:svapdxC1_1a_prnt:panel_svcLimDscr"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:svcLimDscr" name="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:svcLimDscr" class="inputTextarea" readonly="readonly">Persons receiving Assisted Living services may not receive PCA services and PCA is not included on the fee schedule for clients receiving Assisted Living services preventing duplicative billing. The claims would reject as "not being covered under the participant's benefit 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:7:svapdxC1_1a_prnt:svcDelMthPtcDir" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:svcDelMthPtcDir" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:lbl_svcDelMthPtcDir" for="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:svcDelMthPtcDir" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:7: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:7:svapdxC1_1a_prnt:svcDelMthPvdrMgd" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:svcDelMthPvdrMgd" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:lbl_svcDelMthPvdrMgd" for="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:svcDelMthPvdrMgd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:7: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:7:svapdxC1_1a_prnt:svcPvdLegResp" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:svcPvdLegResp" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:lbl_svcPvdLegResp" for="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:svcPvdLegResp" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:txt_lbl_svcPvdLegResp" class="outputText">Legally Responsible Person</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:svcPvdRel" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:svcPvdRel" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:lbl_svcPvdRel" for="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:svcPvdRel" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:txt_lbl_svcPvdRel" class="outputText">Relative</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:svcPvdLegGrd" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:svcPvdLegGrd" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:lbl_svcPvdLegGrd" for="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:svcPvdLegGrd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:txt_lbl_svcPvdLegGrd" class="outputText">Legal Guardian</span></label> </div> </div> </div> <div class="pph"> <label id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:lbl_dtProviderTypes" for="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:dtProviderTypes" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:txt_lbl_dtProviderTypes" class="outputText">Provider Specifications:</span></label> </div> <table id="svapdxC1_1_prnt:dtServicesPrnt:7: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:7:svapdxC1_1a_prnt:dtProviderTypes:hdrProvCat" class="outputText">Provider Category</span></th><th scope="col" ><span id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:dtProviderTypes:hdrProvTyp" class="outputText">Provider Type Title</span></th></tr> </thead><tbody > <tr ><td ><input id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypeID" type="text" name="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypeID" value="223109" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypName" class="outputText">Agency</span></td> <td ><span id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:dtProviderTypes:0:pvdTypeName" class="outputText" style="width: 100%;">Assisted Living Service Agency</span></td> </tr> </tbody> </table> <table id="svapdxC1_1_prnt:dtServicesPrnt:7: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:7:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceTypelbl" class="outputText">Service Type: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:7: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:7:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceNamelbl" class="outputText">Service Name: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceName" class="outputText">Assisted Living</span> </div> </div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdCat" for="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdCat" class="outputText">Provider Category:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" name="svapdxC1_1_prnt:dtServicesPrnt:7: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:7:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdTypeName" for="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:7: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:7:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdTypeName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" name="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" class="inputTextarea" readonly="readonly">Assisted Living Service Agency</textarea></span> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:7: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:7:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualLic" for="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualLic1" class="outputText">License </span><span id="svapdxC1_1_prnt:dtServicesPrnt:7: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:7:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualLic"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" name="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" class="inputTextarea" readonly="readonly">The Assisted Living Service Provider (ALSA) is licensed by the CT Department of Public Health in accordance with chaper 368v. Regulations regarding a Managed Residential Community and the ALSA are found in Regulations of the State of CT agencies in 19-13-D104 and 19-13-D105.</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualCert" for="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualCert1" class="outputText">Certificate </span><span id="svapdxC1_1_prnt:dtServicesPrnt:7: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:7:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualCert"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" name="svapdxC1_1_prnt:dtServicesPrnt:7: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:7:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualOthStd" for="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualOthStd1" class="outputText">Other Standard </span><span id="svapdxC1_1_prnt:dtServicesPrnt:7: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:7:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualOthStd"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" name="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" class="inputTextarea" readonly="readonly"></textarea></span> </div> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:7: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:7:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdVrfEnt" for="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:7: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:7:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdVrfEnt"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" name="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" class="inputTextarea" readonly="readonly">MMIS contractor and Department Quality Assurance staff</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdVrfFreq" for="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:7: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:7:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdVrfFreq"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" name="svapdxC1_1_prnt:dtServicesPrnt:7:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" class="inputTextarea" readonly="readonly">At the time of enrollment as a Medicaid provider and bi-annually 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> <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:8:svapdxC1_1a_prnt:lbl_svcType" for="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:svcType" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:txt_lbl_svcType" class="outputText">Service Type:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:svcType" name="svapdxC1_1_prnt:dtServicesPrnt:8: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:8:svapdxC1_1a_prnt:label1" for="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:svcAltName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:lblUserServiceTitle" class="outputText">Service Title:</span></label> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:panel_svcAltName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:svcAltName" name="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:svcAltName" class="inputTextarea" readonly="readonly">Assistive Technology</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:8:svapdxC1_1a_prnt:lbl_svcTaxCat1" for="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:svcTaxCat1" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:txt_lbl_svcTaxCat1" class="outputText">Category 1:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:svcTaxCat1" name="svapdxC1_1_prnt:dtServicesPrnt:8: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" selected="selected">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"> </option> </select> </div> <div class="rightCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:lbl_svcTaxSubCat1" for="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:svcTaxSubCat1" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:txt_lbl_svcTaxSubCat1" class="outputText">Sub-Category 1:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:svcTaxSubCat1" name="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:svcTaxSubCat1" class="selectOneMenuLong" size="1" disabled="disabled"> <option value="14010">14010 personal emergency response system (PERS)</option> <option value="14020">14020 home and/or vehicle accessibility adaptations</option> <option value="14031" selected="selected">14031 equipment and technology</option> <option value="14032">14032 supplies</option> <option value="99"> </option> </select> </div> </div> <div class="rowContact"> <div class="leftCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:lbl_taxCat2" for="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:svcTaxCat2" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:txt_lbl_taxCat2" class="outputText">Category 2:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:svcTaxCat2" name="svapdxC1_1_prnt:dtServicesPrnt:8: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:8:svapdxC1_1a_prnt:lbl_taxSubCat2" for="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:svcTaxSubCat2" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:txt_lbl_taxSubCat2" class="outputText">Sub-Category 2:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:svcTaxSubCat2" name="svapdxC1_1_prnt:dtServicesPrnt:8: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:8:svapdxC1_1a_prnt:lbl_taxCat3" for="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:svcTaxCat3" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:txt_lbl_taxCat3" class="outputText">Category 3:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:svcTaxCat3" name="svapdxC1_1_prnt:dtServicesPrnt:8: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:8:svapdxC1_1a_prnt:lbl_taxSubCat3" for="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:svcTaxSubCat3" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:txt_lbl_taxSubCat3" class="outputText">Sub-Category 3:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:svcTaxSubCat3" name="svapdxC1_1_prnt:dtServicesPrnt:8: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:8:svapdxC1_1a_prnt:lbl_taxCat4" for="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:svcTaxCat4" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:txt_lbl_taxCat4" class="outputText">Category 4:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:svcTaxCat4" name="svapdxC1_1_prnt:dtServicesPrnt:8: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:8:svapdxC1_1a_prnt:lbl_taxSubCat4" for="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:svcTaxSubCat4" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:txt_lbl_taxSubCat4" class="outputText">Sub-Category 4:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:svcTaxSubCat4" name="svapdxC1_1_prnt:dtServicesPrnt:8: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:8:svapdxC1_1a_prnt:lbl_svcDef" for="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:svcDef" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:lbl_txt_svcDef1" class="outputText">Service Definition</span><span id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:lbl_txt_svcDef2" class="outputTextNB em"> (Scope):</span></label> </div> <div></div> <div Class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:panel_svcDef"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:svcDef" name="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:svcDef" class="inputTextarea" readonly="readonly">An item, piece of equipment, or product system, whether acquired commercially, modified, or customized, that is used to increase, maintain, monitor or improve functional capabilities of participants to perform Activities of Daily Living (ADLs) or Instrumental Activities of Daily Living (IADLs). Assistive technology service means a service that directly assists a participant in the selection, acquisition, or use of an assistive technology device. A. Services consisting of purchasing, leasing, or otherwise providing for the acquisition of assistive technology devices. B. Services consisting of selecting, designing, fitting, customizing, adapting, applying, maintaining, repairing, or replacing assistive technology devices. C. Training or technical assistance for the participant or for the direct benefit of the participant receiving the service and, where appropriate, the family members, guardians, advocates or authorized representatives of the participants.</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:lbl_svcLimDscr" for="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:svcLimDscr" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:8: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:8:svapdxC1_1a_prnt:panel_svcLimDscr"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:svcLimDscr" name="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:svcLimDscr" class="inputTextarea" readonly="readonly">Care plans will be developed based on the needs identified in the comprehensive assessment. The cost of the Assistive Technology cannot exceed the yearly cost of the service it replaces. When an assistive technology device is identified that will support the waiver participant'’s independent functioning, the services will be reduced commensurate with the cost of the service it replaces. This reduction will be made with consideration of the waiver participant'’s health and safety needs. The service shall be capped at an annual cost of $2000.</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:8:svapdxC1_1a_prnt:svcDelMthPtcDir" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:svcDelMthPtcDir" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:lbl_svcDelMthPtcDir" for="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:svcDelMthPtcDir" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:8: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:8:svapdxC1_1a_prnt:svcDelMthPvdrMgd" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:svcDelMthPvdrMgd" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:lbl_svcDelMthPvdrMgd" for="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:svcDelMthPvdrMgd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:8: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:8:svapdxC1_1a_prnt:svcPvdLegResp" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:svcPvdLegResp" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:lbl_svcPvdLegResp" for="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:svcPvdLegResp" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:txt_lbl_svcPvdLegResp" class="outputText">Legally Responsible Person</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:svcPvdRel" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:svcPvdRel" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:lbl_svcPvdRel" for="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:svcPvdRel" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:txt_lbl_svcPvdRel" class="outputText">Relative</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:svcPvdLegGrd" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:svcPvdLegGrd" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:lbl_svcPvdLegGrd" for="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:svcPvdLegGrd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:txt_lbl_svcPvdLegGrd" class="outputText">Legal Guardian</span></label> </div> </div> </div> <div class="pph"> <label id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:lbl_dtProviderTypes" for="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypes" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:txt_lbl_dtProviderTypes" class="outputText">Provider Specifications:</span></label> </div> <table id="svapdxC1_1_prnt:dtServicesPrnt:8: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:8:svapdxC1_1a_prnt:dtProviderTypes:hdrProvCat" class="outputText">Provider Category</span></th><th scope="col" ><span id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypes:hdrProvTyp" class="outputText">Provider Type Title</span></th></tr> </thead><tbody > <tr ><td ><input id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypeID" type="text" name="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypeID" value="223155" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypName" class="outputText">Agency</span></td> <td ><span id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypes:0:pvdTypeName" class="outputText" style="width: 100%;">Agency</span></td> </tr> <tr ><td ><input id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypes:1:providerTypeID" type="text" name="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypes:1:providerTypeID" value="223156" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypes:1:providerTypName" class="outputText">Agency</span></td> <td ><span id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypes:1:pvdTypeName" class="outputText" style="width: 100%;">Pharmacies</span></td> </tr> </tbody> </table> <table id="svapdxC1_1_prnt:dtServicesPrnt:8: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:8:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceTypelbl" class="outputText">Service Type: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:8: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:8:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceNamelbl" class="outputText">Service Name: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceName" class="outputText">Assistive Technology</span> </div> </div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdCat" for="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdCat" class="outputText">Provider Category:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" name="svapdxC1_1_prnt:dtServicesPrnt:8: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:8:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdTypeName" for="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:8: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:8:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdTypeName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" name="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" class="inputTextarea" readonly="readonly">Agency</textarea></span> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:8: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:8:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualLic" for="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualLic1" class="outputText">License </span><span id="svapdxC1_1_prnt:dtServicesPrnt:8: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:8:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualLic"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" name="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" class="inputTextarea" readonly="readonly">For telemonitoring services must be a Home Health Agency licensed in the state of Connecticut as specified in Subsection (k) section 19a-490 of the Connecticut General Statutes.</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualCert" for="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualCert1" class="outputText">Certificate </span><span id="svapdxC1_1_prnt:dtServicesPrnt:8: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:8:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualCert"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" name="svapdxC1_1_prnt:dtServicesPrnt:8: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:8:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualOthStd" for="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualOthStd1" class="outputText">Other Standard </span><span id="svapdxC1_1_prnt:dtServicesPrnt:8: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:8:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualOthStd"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" name="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" class="inputTextarea" readonly="readonly">Medicaid provider status for assistive technology and supplies or agency that obtains Medicaid performing provider status</textarea></span> </div> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:8: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:8:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdVrfEnt" for="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:8: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:8:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdVrfEnt"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" name="svapdxC1_1_prnt:dtServicesPrnt:8: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:8:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdVrfFreq" for="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:8: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:8:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdVrfFreq"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" name="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" class="inputTextarea" readonly="readonly">at the start of service</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:8:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_serviceTypelbl" class="outputText">Service Type: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_serviceType" class="outputText">Other Service</span> </div> <div class="firstIndent"> <span id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_serviceNamelbl" class="outputText">Service Name: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_serviceName" class="outputText">Assistive Technology</span> </div> </div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdCat" for="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdCat" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_lbl_pvdCat" class="outputText">Provider Category:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdCat" name="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:1: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:8:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdTypeName" for="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdTypeName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:8: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:8:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:panel_pvdTypeName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdTypeName" name="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdTypeName" class="inputTextarea" readonly="readonly">Pharmacies</textarea></span> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:8: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:8:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdQualLic" for="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualLic" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_lbl_pvdQualLic1" class="outputText">License </span><span id="svapdxC1_1_prnt:dtServicesPrnt:8: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:8:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:panel_pvdQualLic"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualLic" name="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualLic" class="inputTextarea" readonly="readonly">State of CT Department of Consumer Protection Pharmacy Practice Act: Regulations concerning practice of pharmacy Sec. 20-175-4-6-7</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdQualCert" for="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualCert" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_lbl_pvdQualCert1" class="outputText">Certificate </span><span id="svapdxC1_1_prnt:dtServicesPrnt:8: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:8:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:panel_pvdQualCert"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualCert" name="svapdxC1_1_prnt:dtServicesPrnt:8: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:8:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdQualOthStd" for="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualOthStd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_lbl_pvdQualOthStd1" class="outputText">Other Standard </span><span id="svapdxC1_1_prnt:dtServicesPrnt:8: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:8:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:panel_pvdQualOthStd"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualOthStd" name="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualOthStd" class="inputTextarea" readonly="readonly"></textarea></span> </div> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:8: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:8:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdVrfEnt" for="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdVrfEnt" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:8: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:8:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:panel_pvdVrfEnt"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdVrfEnt" name="svapdxC1_1_prnt:dtServicesPrnt:8: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:8:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdVrfFreq" for="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdVrfFreq" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:8: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:8:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:panel_pvdVrfFreq"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdVrfFreq" name="svapdxC1_1_prnt:dtServicesPrnt:8:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdVrfFreq" class="inputTextarea" readonly="readonly">at the initiation of the service</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:9:svapdxC1_1a_prnt:lbl_svcType" for="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:svcType" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:txt_lbl_svcType" class="outputText">Service Type:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:svcType" name="svapdxC1_1_prnt:dtServicesPrnt:9: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:9:svapdxC1_1a_prnt:label1" for="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:svcAltName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:lblUserServiceTitle" class="outputText">Service Title:</span></label> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:panel_svcAltName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:svcAltName" name="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:svcAltName" class="inputTextarea" readonly="readonly">Bill Payer</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:9:svapdxC1_1a_prnt:lbl_svcTaxCat1" for="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:svcTaxCat1" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:txt_lbl_svcTaxCat1" class="outputText">Category 1:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:svcTaxCat1" name="svapdxC1_1_prnt:dtServicesPrnt:9: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" selected="selected">17 Other Services</option> <option value="99"> </option> </select> </div> <div class="rightCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:lbl_svcTaxSubCat1" for="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:svcTaxSubCat1" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:txt_lbl_svcTaxSubCat1" class="outputText">Sub-Category 1:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:svcTaxSubCat1" name="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:svcTaxSubCat1" class="selectOneMenuLong" size="1" disabled="disabled"> <option value="17010">17010 goods and services</option> <option value="17020">17020 interpreter</option> <option value="17030">17030 housing consultation</option> <option value="17990" selected="selected">17990 other</option> <option value="99"> </option> </select> </div> </div> <div class="rowContact"> <div class="leftCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:lbl_taxCat2" for="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:svcTaxCat2" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:txt_lbl_taxCat2" class="outputText">Category 2:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:svcTaxCat2" name="svapdxC1_1_prnt:dtServicesPrnt:9: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:9:svapdxC1_1a_prnt:lbl_taxSubCat2" for="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:svcTaxSubCat2" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:txt_lbl_taxSubCat2" class="outputText">Sub-Category 2:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:svcTaxSubCat2" name="svapdxC1_1_prnt:dtServicesPrnt:9: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:9:svapdxC1_1a_prnt:lbl_taxCat3" for="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:svcTaxCat3" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:txt_lbl_taxCat3" class="outputText">Category 3:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:svcTaxCat3" name="svapdxC1_1_prnt:dtServicesPrnt:9: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:9:svapdxC1_1a_prnt:lbl_taxSubCat3" for="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:svcTaxSubCat3" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:txt_lbl_taxSubCat3" class="outputText">Sub-Category 3:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:svcTaxSubCat3" name="svapdxC1_1_prnt:dtServicesPrnt:9: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:9:svapdxC1_1a_prnt:lbl_taxCat4" for="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:svcTaxCat4" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:txt_lbl_taxCat4" class="outputText">Category 4:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:svcTaxCat4" name="svapdxC1_1_prnt:dtServicesPrnt:9: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:9:svapdxC1_1a_prnt:lbl_taxSubCat4" for="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:svcTaxSubCat4" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:txt_lbl_taxSubCat4" class="outputText">Sub-Category 4:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:svcTaxSubCat4" name="svapdxC1_1_prnt:dtServicesPrnt:9: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:9:svapdxC1_1a_prnt:lbl_svcDef" for="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:svcDef" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:lbl_txt_svcDef1" class="outputText">Service Definition</span><span id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:lbl_txt_svcDef2" class="outputTextNB em"> (Scope):</span></label> </div> <div></div> <div Class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:panel_svcDef"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:svcDef" name="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:svcDef" class="inputTextarea" readonly="readonly">A bill payer is a trained agency staff member who is paired with a client that is having difficulty managing their routine monthly finances. Staff member assists with writing checks that client signs, budgeting, paying bills on time, balancing checkbook, Social Security and Medicare questions and problems. The person can assist with applications for financial assistance programs, medical insurance claims and other financial matters including applications for senior housing and medical insurance. Electronic bill payment is permitted as part of this service.</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:lbl_svcLimDscr" for="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:svcLimDscr" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:9: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:9:svapdxC1_1a_prnt:panel_svcLimDscr"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:svcLimDscr" name="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:svcLimDscr" class="inputTextarea" readonly="readonly">Service is limited to 3 hours per month.</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:9:svapdxC1_1a_prnt:svcDelMthPtcDir" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:svcDelMthPtcDir" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:lbl_svcDelMthPtcDir" for="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:svcDelMthPtcDir" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:9: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:9:svapdxC1_1a_prnt:svcDelMthPvdrMgd" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:svcDelMthPvdrMgd" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:lbl_svcDelMthPvdrMgd" for="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:svcDelMthPvdrMgd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:9: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:9:svapdxC1_1a_prnt:svcPvdLegResp" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:svcPvdLegResp" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:lbl_svcPvdLegResp" for="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:svcPvdLegResp" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:txt_lbl_svcPvdLegResp" class="outputText">Legally Responsible Person</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:svcPvdRel" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:svcPvdRel" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:lbl_svcPvdRel" for="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:svcPvdRel" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:txt_lbl_svcPvdRel" class="outputText">Relative</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:svcPvdLegGrd" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:svcPvdLegGrd" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:lbl_svcPvdLegGrd" for="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:svcPvdLegGrd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:txt_lbl_svcPvdLegGrd" class="outputText">Legal Guardian</span></label> </div> </div> </div> <div class="pph"> <label id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:lbl_dtProviderTypes" for="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:dtProviderTypes" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:txt_lbl_dtProviderTypes" class="outputText">Provider Specifications:</span></label> </div> <table id="svapdxC1_1_prnt:dtServicesPrnt:9: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:9:svapdxC1_1a_prnt:dtProviderTypes:hdrProvCat" class="outputText">Provider Category</span></th><th scope="col" ><span id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:dtProviderTypes:hdrProvTyp" class="outputText">Provider Type Title</span></th></tr> </thead><tbody > <tr ><td ><input id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypeID" type="text" name="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypeID" value="225660" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypName" class="outputText">Agency</span></td> <td ><span id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:dtProviderTypes:0:pvdTypeName" class="outputText" style="width: 100%;">Agency</span></td> </tr> </tbody> </table> <table id="svapdxC1_1_prnt:dtServicesPrnt:9: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:9:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceTypelbl" class="outputText">Service Type: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:9: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:9:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceNamelbl" class="outputText">Service Name: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceName" class="outputText">Bill Payer</span> </div> </div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdCat" for="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdCat" class="outputText">Provider Category:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" name="svapdxC1_1_prnt:dtServicesPrnt:9: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:9:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdTypeName" for="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:9: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:9:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdTypeName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" name="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" class="inputTextarea" readonly="readonly">Agency</textarea></span> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:9: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:9:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualLic" for="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualLic1" class="outputText">License </span><span id="svapdxC1_1_prnt:dtServicesPrnt:9: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:9:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualLic"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" name="svapdxC1_1_prnt:dtServicesPrnt:9: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:9:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualCert" for="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualCert1" class="outputText">Certificate </span><span id="svapdxC1_1_prnt:dtServicesPrnt:9: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:9:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualCert"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" name="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" class="inputTextarea" readonly="readonly">If the agency provider is a Homemaker/Companion Agency, they must be registered with the Department of Consumer Protection.</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualOthStd" for="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualOthStd1" class="outputText">Other Standard </span><span id="svapdxC1_1_prnt:dtServicesPrnt:9: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:9:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualOthStd"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" name="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" class="inputTextarea" readonly="readonly">Agency providing bill payer service is bonded and insured against fraudulent behavior. Bill payer's activities are overseen by the agency administrator or their designee. Cases are regularly reviewed and coaching is provided to the bill payer as needed. Online banking and bill paying is an option as part of this service</textarea></span> </div> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:9: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:9:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdVrfEnt" for="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:9: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:9:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdVrfEnt"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" name="svapdxC1_1_prnt:dtServicesPrnt:9: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:9:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdVrfFreq" for="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:9: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:9:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdVrfFreq"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" name="svapdxC1_1_prnt:dtServicesPrnt:9:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" class="inputTextarea" readonly="readonly">At the time of enrollment and every two 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> </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:10:svapdxC1_1a_prnt:lbl_svcType" for="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:svcType" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:txt_lbl_svcType" class="outputText">Service Type:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:svcType" name="svapdxC1_1_prnt:dtServicesPrnt:10: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:10:svapdxC1_1a_prnt:label1" for="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:svcAltName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:lblUserServiceTitle" class="outputText">Service Title:</span></label> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:panel_svcAltName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:svcAltName" name="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:svcAltName" class="inputTextarea" readonly="readonly">Care Transitions</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:10:svapdxC1_1a_prnt:lbl_svcTaxCat1" for="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:svcTaxCat1" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:txt_lbl_svcTaxCat1" class="outputText">Category 1:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:svcTaxCat1" name="svapdxC1_1_prnt:dtServicesPrnt:10: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" selected="selected">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"> </option> </select> </div> <div class="rightCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:lbl_svcTaxSubCat1" for="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:svcTaxSubCat1" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:txt_lbl_svcTaxSubCat1" class="outputText">Sub-Category 1:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:svcTaxSubCat1" name="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:svcTaxSubCat1" class="selectOneMenuLong" size="1" disabled="disabled"> <option value="13010" selected="selected">13010 participant training</option> <option value="99"> </option> </select> </div> </div> <div class="rowContact"> <div class="leftCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:lbl_taxCat2" for="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:svcTaxCat2" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:txt_lbl_taxCat2" class="outputText">Category 2:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:svcTaxCat2" name="svapdxC1_1_prnt:dtServicesPrnt:10: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:10:svapdxC1_1a_prnt:lbl_taxSubCat2" for="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:svcTaxSubCat2" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:txt_lbl_taxSubCat2" class="outputText">Sub-Category 2:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:svcTaxSubCat2" name="svapdxC1_1_prnt:dtServicesPrnt:10: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:10:svapdxC1_1a_prnt:lbl_taxCat3" for="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:svcTaxCat3" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:txt_lbl_taxCat3" class="outputText">Category 3:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:svcTaxCat3" name="svapdxC1_1_prnt:dtServicesPrnt:10: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:10:svapdxC1_1a_prnt:lbl_taxSubCat3" for="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:svcTaxSubCat3" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:txt_lbl_taxSubCat3" class="outputText">Sub-Category 3:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:svcTaxSubCat3" name="svapdxC1_1_prnt:dtServicesPrnt:10: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:10:svapdxC1_1a_prnt:lbl_taxCat4" for="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:svcTaxCat4" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:txt_lbl_taxCat4" class="outputText">Category 4:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:svcTaxCat4" name="svapdxC1_1_prnt:dtServicesPrnt:10: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:10:svapdxC1_1a_prnt:lbl_taxSubCat4" for="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:svcTaxSubCat4" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:txt_lbl_taxSubCat4" class="outputText">Sub-Category 4:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:svcTaxSubCat4" name="svapdxC1_1_prnt:dtServicesPrnt:10: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:10:svapdxC1_1a_prnt:lbl_svcDef" for="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:svcDef" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:lbl_txt_svcDef1" class="outputText">Service Definition</span><span id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:lbl_txt_svcDef2" class="outputTextNB em"> (Scope):</span></label> </div> <div></div> <div Class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:panel_svcDef"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:svcDef" name="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:svcDef" class="inputTextarea" readonly="readonly">An evidence-based set of actions designed to ensure health care coordination, continuity and avoidance of preventable poor outcomes in vulnerable participants as they move between institutional and home and community based settings. Core activities include: building a trusting relationship, facilitating coaching and teaching, helping participants identify "red flags" to prevent readmissions, understand contributing factors for current admission, scheduling timely follow up with primary care provider, partnering with hospital care coordinators to enhance continuity of care. Service includes either a home visit or telephone follow up no more than 72 hours after discharge.</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:lbl_svcLimDscr" for="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:svcLimDscr" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:10: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:10:svapdxC1_1a_prnt:panel_svcLimDscr"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:svcLimDscr" name="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:svcLimDscr" class="inputTextarea" readonly="readonly">Available only to those who have been enrolled in the waiver as an active participant which means they are receiving waiver services. Not available to waiver applicants. Limited to no more than one unit in 60 days. Cannot be billed concurrently with a status review.</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:10:svapdxC1_1a_prnt:svcDelMthPtcDir" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:svcDelMthPtcDir" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:lbl_svcDelMthPtcDir" for="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:svcDelMthPtcDir" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:10: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:10:svapdxC1_1a_prnt:svcDelMthPvdrMgd" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:svcDelMthPvdrMgd" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:lbl_svcDelMthPvdrMgd" for="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:svcDelMthPvdrMgd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:10: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:10:svapdxC1_1a_prnt:svcPvdLegResp" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:svcPvdLegResp" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:lbl_svcPvdLegResp" for="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:svcPvdLegResp" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:txt_lbl_svcPvdLegResp" class="outputText">Legally Responsible Person</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:svcPvdRel" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:svcPvdRel" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:lbl_svcPvdRel" for="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:svcPvdRel" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:txt_lbl_svcPvdRel" class="outputText">Relative</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:svcPvdLegGrd" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:svcPvdLegGrd" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:lbl_svcPvdLegGrd" for="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:svcPvdLegGrd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:txt_lbl_svcPvdLegGrd" class="outputText">Legal Guardian</span></label> </div> </div> </div> <div class="pph"> <label id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:lbl_dtProviderTypes" for="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:dtProviderTypes" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:txt_lbl_dtProviderTypes" class="outputText">Provider Specifications:</span></label> </div> <table id="svapdxC1_1_prnt:dtServicesPrnt:10: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:10:svapdxC1_1a_prnt:dtProviderTypes:hdrProvCat" class="outputText">Provider Category</span></th><th scope="col" ><span id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:dtProviderTypes:hdrProvTyp" class="outputText">Provider Type Title</span></th></tr> </thead><tbody > <tr ><td ><input id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypeID" type="text" name="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypeID" value="225839" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypName" class="outputText">Agency</span></td> <td ><span id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:dtProviderTypes:0:pvdTypeName" class="outputText" style="width: 100%;">Access Agency</span></td> </tr> </tbody> </table> <table id="svapdxC1_1_prnt:dtServicesPrnt:10: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:10:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceTypelbl" class="outputText">Service Type: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:10: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:10:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceNamelbl" class="outputText">Service Name: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceName" class="outputText">Care Transitions</span> </div> </div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdCat" for="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdCat" class="outputText">Provider Category:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" name="svapdxC1_1_prnt:dtServicesPrnt:10: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:10:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdTypeName" for="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:10: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:10:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdTypeName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" name="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" class="inputTextarea" readonly="readonly">Access Agency</textarea></span> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:10: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:10:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualLic" for="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualLic1" class="outputText">License </span><span id="svapdxC1_1_prnt:dtServicesPrnt:10: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:10:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualLic"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" name="svapdxC1_1_prnt:dtServicesPrnt:10: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. 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. A licensed social worker is preferred for this service but not required.</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualCert" for="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualCert1" class="outputText">Certificate </span><span id="svapdxC1_1_prnt:dtServicesPrnt:10: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:10:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualCert"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" name="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" class="inputTextarea" readonly="readonly">The registered nurse shall hold a license to practice nursing in the State of CT. Care Managers are encouraged but not required to be certified as a long term care manager.</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualOthStd" for="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualOthStd1" class="outputText">Other Standard </span><span id="svapdxC1_1_prnt:dtServicesPrnt:10: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:10:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualOthStd"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" name="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" class="inputTextarea" readonly="readonly"></textarea></span> </div> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:10: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:10:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdVrfEnt" for="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:10: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:10:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdVrfEnt"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" name="svapdxC1_1_prnt:dtServicesPrnt:10: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:10:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdVrfFreq" for="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:10: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:10:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdVrfFreq"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" name="svapdxC1_1_prnt:dtServicesPrnt:10:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" class="inputTextarea" readonly="readonly">At the time of hire and annually at the time of annual performance appraisal.</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:11:svapdxC1_1a_prnt:lbl_svcType" for="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:svcType" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:txt_lbl_svcType" class="outputText">Service Type:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:svcType" name="svapdxC1_1_prnt:dtServicesPrnt:11: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:11:svapdxC1_1a_prnt:label1" for="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:svcAltName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:lblUserServiceTitle" class="outputText">Service Title:</span></label> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:panel_svcAltName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:svcAltName" name="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:svcAltName" class="inputTextarea" readonly="readonly">Chore Services</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:11:svapdxC1_1a_prnt:lbl_svcTaxCat1" for="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:svcTaxCat1" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:txt_lbl_svcTaxCat1" class="outputText">Category 1:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:svcTaxCat1" name="svapdxC1_1_prnt:dtServicesPrnt:11: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" selected="selected">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"> </option> </select> </div> <div class="rightCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:lbl_svcTaxSubCat1" for="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:svcTaxSubCat1" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:txt_lbl_svcTaxSubCat1" class="outputText">Sub-Category 1:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:svcTaxSubCat1" name="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:svcTaxSubCat1" class="selectOneMenuLong" size="1" disabled="disabled"> <option value="08010">08010 home-based habilitation</option> <option value="08020">08020 home health aide</option> <option value="08030">08030 personal care</option> <option value="08040">08040 companion</option> <option value="08050">08050 homemaker</option> <option value="08060" selected="selected">08060 chore</option> <option value="99"> </option> </select> </div> </div> <div class="rowContact"> <div class="leftCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:lbl_taxCat2" for="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:svcTaxCat2" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:txt_lbl_taxCat2" class="outputText">Category 2:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:svcTaxCat2" name="svapdxC1_1_prnt:dtServicesPrnt:11: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:11:svapdxC1_1a_prnt:lbl_taxSubCat2" for="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:svcTaxSubCat2" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:txt_lbl_taxSubCat2" class="outputText">Sub-Category 2:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:svcTaxSubCat2" name="svapdxC1_1_prnt:dtServicesPrnt:11: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:11:svapdxC1_1a_prnt:lbl_taxCat3" for="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:svcTaxCat3" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:txt_lbl_taxCat3" class="outputText">Category 3:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:svcTaxCat3" name="svapdxC1_1_prnt:dtServicesPrnt:11: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:11:svapdxC1_1a_prnt:lbl_taxSubCat3" for="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:svcTaxSubCat3" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:txt_lbl_taxSubCat3" class="outputText">Sub-Category 3:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:svcTaxSubCat3" name="svapdxC1_1_prnt:dtServicesPrnt:11: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:11:svapdxC1_1a_prnt:lbl_taxCat4" for="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:svcTaxCat4" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:txt_lbl_taxCat4" class="outputText">Category 4:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:svcTaxCat4" name="svapdxC1_1_prnt:dtServicesPrnt:11: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:11:svapdxC1_1a_prnt:lbl_taxSubCat4" for="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:svcTaxSubCat4" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:txt_lbl_taxSubCat4" class="outputText">Sub-Category 4:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:svcTaxSubCat4" name="svapdxC1_1_prnt:dtServicesPrnt:11: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:11:svapdxC1_1a_prnt:lbl_svcDef" for="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:svcDef" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:lbl_txt_svcDef1" class="outputText">Service Definition</span><span id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:lbl_txt_svcDef2" class="outputTextNB em"> (Scope):</span></label> </div> <div></div> <div Class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:panel_svcDef"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:svcDef" name="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:svcDef" class="inputTextarea" readonly="readonly">Services needed to maintain the home in a clean, sanitary and safe environment. This service includes heavy household chores such as washing floors, windows and walls, tacking down loose rugs and tiles, moving heavy items of furniture in order to provide safe access and egress. These services will be provided only in cases where neither the individual, nor anyone else in the household, is capable of performing or financially providing for them, and where no other relative, caregiver, landlord, community/volunteer agency, or third party payor is capable of or responsible for their provision. In the case of rental property, the responsibility of the landlord, pursuant to the lease agreement, will be examined prior to any authorization of service.</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:lbl_svcLimDscr" for="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:svcLimDscr" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:11: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:11:svapdxC1_1a_prnt:panel_svcLimDscr"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:svcLimDscr" name="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:svcLimDscr" class="inputTextarea" readonly="readonly">When an individual requires one-time only unique or specialized services in order to maintain a healthy and safe environment, they may receive highly skilled chore services which include but are not limited to moving, extensive cleaning or extermination services. Highly skilled chore services are subject to prior authorization by the department.</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:11:svapdxC1_1a_prnt:svcDelMthPtcDir" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:svcDelMthPtcDir" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:lbl_svcDelMthPtcDir" for="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:svcDelMthPtcDir" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:11: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:11:svapdxC1_1a_prnt:svcDelMthPvdrMgd" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:svcDelMthPvdrMgd" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:lbl_svcDelMthPvdrMgd" for="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:svcDelMthPvdrMgd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:11: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:11:svapdxC1_1a_prnt:svcPvdLegResp" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:svcPvdLegResp" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:lbl_svcPvdLegResp" for="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:svcPvdLegResp" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:txt_lbl_svcPvdLegResp" class="outputText">Legally Responsible Person</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:svcPvdRel" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:svcPvdRel" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:lbl_svcPvdRel" for="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:svcPvdRel" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:txt_lbl_svcPvdRel" class="outputText">Relative</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:svcPvdLegGrd" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:svcPvdLegGrd" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:lbl_svcPvdLegGrd" for="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:svcPvdLegGrd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:txt_lbl_svcPvdLegGrd" class="outputText">Legal Guardian</span></label> </div> </div> </div> <div class="pph"> <label id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:lbl_dtProviderTypes" for="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypes" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:txt_lbl_dtProviderTypes" class="outputText">Provider Specifications:</span></label> </div> <table id="svapdxC1_1_prnt:dtServicesPrnt:11: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:11:svapdxC1_1a_prnt:dtProviderTypes:hdrProvCat" class="outputText">Provider Category</span></th><th scope="col" ><span id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypes:hdrProvTyp" class="outputText">Provider Type Title</span></th></tr> </thead><tbody > <tr ><td ><input id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypeID" type="text" name="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypeID" value="223241" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypName" class="outputText">Agency</span></td> <td ><span id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypes:0:pvdTypeName" class="outputText" style="width: 100%;">Provider Agency</span></td> </tr> <tr ><td ><input id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypes:1:providerTypeID" type="text" name="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypes:1:providerTypeID" value="223240" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypes:1:providerTypName" class="outputText">Individual</span></td> <td ><span id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypes:1:pvdTypeName" class="outputText" style="width: 100%;">Licensed Contractor</span></td> </tr> </tbody> </table> <table id="svapdxC1_1_prnt:dtServicesPrnt:11: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:11:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceTypelbl" class="outputText">Service Type: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:11: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:11:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceNamelbl" class="outputText">Service Name: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceName" class="outputText">Chore Services</span> </div> </div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdCat" for="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdCat" class="outputText">Provider Category:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" name="svapdxC1_1_prnt:dtServicesPrnt:11: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:11:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdTypeName" for="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:11: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:11:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdTypeName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" name="svapdxC1_1_prnt:dtServicesPrnt:11: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:11: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:11:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualLic" for="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualLic1" class="outputText">License </span><span id="svapdxC1_1_prnt:dtServicesPrnt:11: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:11:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualLic"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" name="svapdxC1_1_prnt:dtServicesPrnt:11: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:11:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualCert" for="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualCert1" class="outputText">Certificate </span><span id="svapdxC1_1_prnt:dtServicesPrnt:11: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:11:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualCert"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" name="svapdxC1_1_prnt:dtServicesPrnt:11: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:11:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualOthStd" for="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualOthStd1" class="outputText">Other Standard </span><span id="svapdxC1_1_prnt:dtServicesPrnt:11: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:11:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualOthStd"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" name="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" class="inputTextarea" readonly="readonly">If provider is a homemaker/companion/chore agency, they must be registered with the Department of Consumer Protection. Chore services providers shall demonstrate the ability to meet the needs of the individual seeking services.</textarea></span> </div> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:11: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:11:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdVrfEnt" for="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:11: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:11:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdVrfEnt"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" name="svapdxC1_1_prnt:dtServicesPrnt:11: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:11:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdVrfFreq" for="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:11: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:11:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdVrfFreq"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" name="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" class="inputTextarea" readonly="readonly">At the time of enrollment 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> <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:11:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_serviceTypelbl" class="outputText">Service Type: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_serviceType" class="outputText">Other Service</span> </div> <div class="firstIndent"> <span id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_serviceNamelbl" class="outputText">Service Name: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_serviceName" class="outputText">Chore Services</span> </div> </div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdCat" for="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdCat" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_lbl_pvdCat" class="outputText">Provider Category:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdCat" name="svapdxC1_1_prnt:dtServicesPrnt:11: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:11:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdTypeName" for="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdTypeName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:11: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:11:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:panel_pvdTypeName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdTypeName" name="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdTypeName" class="inputTextarea" readonly="readonly">Licensed Contractor</textarea></span> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:11: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:11:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdQualLic" for="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualLic" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_lbl_pvdQualLic1" class="outputText">License </span><span id="svapdxC1_1_prnt:dtServicesPrnt:11: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:11:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:panel_pvdQualLic"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualLic" name="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualLic" class="inputTextarea" readonly="readonly">Electrician, plumbers and other contractors must hold the appropriate license to perform highly skilled chore services.</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdQualCert" for="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualCert" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_lbl_pvdQualCert1" class="outputText">Certificate </span><span id="svapdxC1_1_prnt:dtServicesPrnt:11: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:11:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:panel_pvdQualCert"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualCert" name="svapdxC1_1_prnt:dtServicesPrnt:11: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:11:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdQualOthStd" for="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualOthStd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_lbl_pvdQualOthStd1" class="outputText">Other Standard </span><span id="svapdxC1_1_prnt:dtServicesPrnt:11: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:11:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:panel_pvdQualOthStd"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualOthStd" name="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualOthStd" class="inputTextarea" readonly="readonly"></textarea></span> </div> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:11: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:11:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdVrfEnt" for="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdVrfEnt" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:11: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:11:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:panel_pvdVrfEnt"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdVrfEnt" name="svapdxC1_1_prnt:dtServicesPrnt:11: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:11:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdVrfFreq" for="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdVrfFreq" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:11: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:11:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:panel_pvdVrfFreq"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdVrfFreq" name="svapdxC1_1_prnt:dtServicesPrnt:11:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdVrfFreq" class="inputTextarea" readonly="readonly">At the time of service</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:12:svapdxC1_1a_prnt:lbl_svcType" for="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:svcType" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:txt_lbl_svcType" class="outputText">Service Type:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:svcType" name="svapdxC1_1_prnt:dtServicesPrnt:12: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:12:svapdxC1_1a_prnt:label1" for="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:svcAltName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:lblUserServiceTitle" class="outputText">Service Title:</span></label> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:panel_svcAltName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:svcAltName" name="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:svcAltName" class="inputTextarea" readonly="readonly">Chronic Disease Self-Management Program</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:12:svapdxC1_1a_prnt:lbl_svcTaxCat1" for="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:svcTaxCat1" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:txt_lbl_svcTaxCat1" class="outputText">Category 1:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:svcTaxCat1" name="svapdxC1_1_prnt:dtServicesPrnt:12: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" selected="selected">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"> </option> </select> </div> <div class="rightCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:lbl_svcTaxSubCat1" for="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:svcTaxSubCat1" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:txt_lbl_svcTaxSubCat1" class="outputText">Sub-Category 1:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:svcTaxSubCat1" name="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:svcTaxSubCat1" class="selectOneMenuLong" size="1" disabled="disabled"> <option value="13010" selected="selected">13010 participant training</option> <option value="99"> </option> </select> </div> </div> <div class="rowContact"> <div class="leftCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:lbl_taxCat2" for="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:svcTaxCat2" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:txt_lbl_taxCat2" class="outputText">Category 2:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:svcTaxCat2" name="svapdxC1_1_prnt:dtServicesPrnt:12: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:12:svapdxC1_1a_prnt:lbl_taxSubCat2" for="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:svcTaxSubCat2" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:txt_lbl_taxSubCat2" class="outputText">Sub-Category 2:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:svcTaxSubCat2" name="svapdxC1_1_prnt:dtServicesPrnt:12: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:12:svapdxC1_1a_prnt:lbl_taxCat3" for="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:svcTaxCat3" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:txt_lbl_taxCat3" class="outputText">Category 3:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:svcTaxCat3" name="svapdxC1_1_prnt:dtServicesPrnt:12: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:12:svapdxC1_1a_prnt:lbl_taxSubCat3" for="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:svcTaxSubCat3" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:txt_lbl_taxSubCat3" class="outputText">Sub-Category 3:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:svcTaxSubCat3" name="svapdxC1_1_prnt:dtServicesPrnt:12: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:12:svapdxC1_1a_prnt:lbl_taxCat4" for="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:svcTaxCat4" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:txt_lbl_taxCat4" class="outputText">Category 4:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:svcTaxCat4" name="svapdxC1_1_prnt:dtServicesPrnt:12: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:12:svapdxC1_1a_prnt:lbl_taxSubCat4" for="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:svcTaxSubCat4" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:txt_lbl_taxSubCat4" class="outputText">Sub-Category 4:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:svcTaxSubCat4" name="svapdxC1_1_prnt:dtServicesPrnt:12: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:12:svapdxC1_1a_prnt:lbl_svcDef" for="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:svcDef" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:lbl_txt_svcDef1" class="outputText">Service Definition</span><span id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:lbl_txt_svcDef2" class="outputTextNB em"> (Scope):</span></label> </div> <div></div> <div Class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:panel_svcDef"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:svcDef" name="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:svcDef" class="inputTextarea" readonly="readonly">The Chronic Disease Self-Management Program (Live-Well) is a workshop given two and a half hours, once a week, for six weeks, in community settings such as senior centers, churches, libraries and hospitals. People with different chronic health problems attend together. Workshops are facilitated by two trained leaders, one or both of whom are non-health professionals with chronic diseases themselves. Subjects covered include: 1) techniques to deal with problems such as frustration, fatigue, pain and isolation, 2) appropriate exercise for maintaining and improving strength, flexibility, and endurance, 3) appropriate use of medications, 4) communicating effectively with family, friends, and health professionals, 5) nutrition, 6) decision making, and 7) how to evaluate new treatments. The program is helpful for people with chronic conditions, as it gives them the skills to coordinate all the things needed to manage their health, as well as to help them keep active in their lives. The therapeutic goals of the service are adjustment to serious impairments, maintenance or restoration of physical functioning, self management of chronic disease, acquisition of skills to address minor depression, management of personal care and development of skills to work with care providers including behavior management. The program is also available in Spanish and is called Tomando Control de su Salud.</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:lbl_svcLimDscr" for="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:svcLimDscr" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:12: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:12:svapdxC1_1a_prnt:panel_svcLimDscr"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:svcLimDscr" name="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:svcLimDscr" class="inputTextarea" readonly="readonly">The program provides up to six sessions of two hours each. The participant is strongly encouraged to attend all six sessions. The service is limited to one six session service per calendar year.</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:12:svapdxC1_1a_prnt:svcDelMthPtcDir" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:svcDelMthPtcDir" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:lbl_svcDelMthPtcDir" for="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:svcDelMthPtcDir" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:12: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:12:svapdxC1_1a_prnt:svcDelMthPvdrMgd" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:svcDelMthPvdrMgd" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:lbl_svcDelMthPvdrMgd" for="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:svcDelMthPvdrMgd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:12: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:12:svapdxC1_1a_prnt:svcPvdLegResp" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:svcPvdLegResp" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:lbl_svcPvdLegResp" for="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:svcPvdLegResp" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:txt_lbl_svcPvdLegResp" class="outputText">Legally Responsible Person</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:svcPvdRel" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:svcPvdRel" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:lbl_svcPvdRel" for="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:svcPvdRel" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:txt_lbl_svcPvdRel" class="outputText">Relative</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:svcPvdLegGrd" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:svcPvdLegGrd" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:lbl_svcPvdLegGrd" for="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:svcPvdLegGrd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:txt_lbl_svcPvdLegGrd" class="outputText">Legal Guardian</span></label> </div> </div> </div> <div class="pph"> <label id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:lbl_dtProviderTypes" for="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypes" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:txt_lbl_dtProviderTypes" class="outputText">Provider Specifications:</span></label> </div> <table id="svapdxC1_1_prnt:dtServicesPrnt:12: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:12:svapdxC1_1a_prnt:dtProviderTypes:hdrProvCat" class="outputText">Provider Category</span></th><th scope="col" ><span id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypes:hdrProvTyp" class="outputText">Provider Type Title</span></th></tr> </thead><tbody > <tr ><td ><input id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypeID" type="text" name="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypeID" value="225659" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypName" class="outputText">Agency</span></td> <td ><span id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypes:0:pvdTypeName" class="outputText" style="width: 100%;">Agency</span></td> </tr> <tr ><td ><input id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypes:1:providerTypeID" type="text" name="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypes:1:providerTypeID" value="225658" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypes:1:providerTypName" class="outputText">Individual</span></td> <td ><span id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypes:1:pvdTypeName" class="outputText" style="width: 100%;">Individual Chronic Disease Self Management Trainer</span></td> </tr> </tbody> </table> <table id="svapdxC1_1_prnt:dtServicesPrnt:12: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:12:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceTypelbl" class="outputText">Service Type: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:12: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:12:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceNamelbl" class="outputText">Service Name: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceName" class="outputText">Chronic Disease Self-Management Program</span> </div> </div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdCat" for="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdCat" class="outputText">Provider Category:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" name="svapdxC1_1_prnt:dtServicesPrnt:12: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:12:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdTypeName" for="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:12: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:12:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdTypeName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" name="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" class="inputTextarea" readonly="readonly">Agency</textarea></span> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:12: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:12:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualLic" for="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualLic1" class="outputText">License </span><span id="svapdxC1_1_prnt:dtServicesPrnt:12: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:12:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualLic"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" name="svapdxC1_1_prnt:dtServicesPrnt:12: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:12:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualCert" for="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualCert1" class="outputText">Certificate </span><span id="svapdxC1_1_prnt:dtServicesPrnt:12: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:12:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualCert"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" name="svapdxC1_1_prnt:dtServicesPrnt:12: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:12:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualOthStd" for="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualOthStd1" class="outputText">Other Standard </span><span id="svapdxC1_1_prnt:dtServicesPrnt:12: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:12:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualOthStd"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" name="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" class="inputTextarea" readonly="readonly">Individual Employee Qualification: Certification in an evidence- based chronic disease self-management training program such as the Stanford University Chronic Disease Self Management Program.</textarea></span> </div> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:12: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:12:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdVrfEnt" for="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:12: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:12:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdVrfEnt"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" name="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" class="inputTextarea" readonly="readonly">Provider agency and fiscal intermediary</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdVrfFreq" for="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:12: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:12:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdVrfFreq"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" name="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" class="inputTextarea" readonly="readonly">Upon initial contracting and every two 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:12:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_serviceTypelbl" class="outputText">Service Type: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_serviceType" class="outputText">Other Service</span> </div> <div class="firstIndent"> <span id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_serviceNamelbl" class="outputText">Service Name: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_serviceName" class="outputText">Chronic Disease Self-Management Program</span> </div> </div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdCat" for="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdCat" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_lbl_pvdCat" class="outputText">Provider Category:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdCat" name="svapdxC1_1_prnt:dtServicesPrnt:12: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:12:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdTypeName" for="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdTypeName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:12: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:12:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:panel_pvdTypeName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdTypeName" name="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdTypeName" class="inputTextarea" readonly="readonly">Individual Chronic Disease Self Management Trainer</textarea></span> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:12: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:12:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdQualLic" for="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualLic" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_lbl_pvdQualLic1" class="outputText">License </span><span id="svapdxC1_1_prnt:dtServicesPrnt:12: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:12:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:panel_pvdQualLic"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualLic" name="svapdxC1_1_prnt:dtServicesPrnt:12: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:12:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdQualCert" for="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualCert" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_lbl_pvdQualCert1" class="outputText">Certificate </span><span id="svapdxC1_1_prnt:dtServicesPrnt:12: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:12:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:panel_pvdQualCert"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualCert" name="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualCert" class="inputTextarea" readonly="readonly">Certification in an evidence-based chronic disease self management training program such as the Stanford University Chronic Disease Self Management Program (CDSMP).</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdQualOthStd" for="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualOthStd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_lbl_pvdQualOthStd1" class="outputText">Other Standard </span><span id="svapdxC1_1_prnt:dtServicesPrnt:12: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:12:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:panel_pvdQualOthStd"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualOthStd" name="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualOthStd" class="inputTextarea" readonly="readonly"></textarea></span> </div> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:12: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:12:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdVrfEnt" for="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdVrfEnt" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:12: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:12:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:panel_pvdVrfEnt"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdVrfEnt" name="svapdxC1_1_prnt:dtServicesPrnt:12: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:12:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdVrfFreq" for="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdVrfFreq" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:12: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:12:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:panel_pvdVrfFreq"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdVrfFreq" name="svapdxC1_1_prnt:dtServicesPrnt:12:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdVrfFreq" class="inputTextarea" readonly="readonly">Upon initial contracting and every two 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> </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:13:svapdxC1_1a_prnt:lbl_svcType" for="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:svcType" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:txt_lbl_svcType" class="outputText">Service Type:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:svcType" name="svapdxC1_1_prnt:dtServicesPrnt:13: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:13:svapdxC1_1a_prnt:label1" for="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:svcAltName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:lblUserServiceTitle" class="outputText">Service Title:</span></label> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:panel_svcAltName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:svcAltName" name="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:svcAltName" class="inputTextarea" readonly="readonly">Companion</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:13:svapdxC1_1a_prnt:lbl_svcTaxCat1" for="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:svcTaxCat1" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:txt_lbl_svcTaxCat1" class="outputText">Category 1:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:svcTaxCat1" name="svapdxC1_1_prnt:dtServicesPrnt:13: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" selected="selected">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"> </option> </select> </div> <div class="rightCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:lbl_svcTaxSubCat1" for="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:svcTaxSubCat1" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:txt_lbl_svcTaxSubCat1" class="outputText">Sub-Category 1:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:svcTaxSubCat1" name="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:svcTaxSubCat1" class="selectOneMenuLong" size="1" disabled="disabled"> <option value="08010">08010 home-based habilitation</option> <option value="08020">08020 home health aide</option> <option value="08030">08030 personal care</option> <option value="08040" selected="selected">08040 companion</option> <option value="08050">08050 homemaker</option> <option value="08060">08060 chore</option> <option value="99"> </option> </select> </div> </div> <div class="rowContact"> <div class="leftCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:lbl_taxCat2" for="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:svcTaxCat2" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:txt_lbl_taxCat2" class="outputText">Category 2:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:svcTaxCat2" name="svapdxC1_1_prnt:dtServicesPrnt:13: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:13:svapdxC1_1a_prnt:lbl_taxSubCat2" for="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:svcTaxSubCat2" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:txt_lbl_taxSubCat2" class="outputText">Sub-Category 2:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:svcTaxSubCat2" name="svapdxC1_1_prnt:dtServicesPrnt:13: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:13:svapdxC1_1a_prnt:lbl_taxCat3" for="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:svcTaxCat3" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:txt_lbl_taxCat3" class="outputText">Category 3:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:svcTaxCat3" name="svapdxC1_1_prnt:dtServicesPrnt:13: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:13:svapdxC1_1a_prnt:lbl_taxSubCat3" for="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:svcTaxSubCat3" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:txt_lbl_taxSubCat3" class="outputText">Sub-Category 3:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:svcTaxSubCat3" name="svapdxC1_1_prnt:dtServicesPrnt:13: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:13:svapdxC1_1a_prnt:lbl_taxCat4" for="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:svcTaxCat4" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:txt_lbl_taxCat4" class="outputText">Category 4:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:svcTaxCat4" name="svapdxC1_1_prnt:dtServicesPrnt:13: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:13:svapdxC1_1a_prnt:lbl_taxSubCat4" for="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:svcTaxSubCat4" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:txt_lbl_taxSubCat4" class="outputText">Sub-Category 4:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:svcTaxSubCat4" name="svapdxC1_1_prnt:dtServicesPrnt:13: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:13:svapdxC1_1a_prnt:lbl_svcDef" for="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:svcDef" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:lbl_txt_svcDef1" class="outputText">Service Definition</span><span id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:lbl_txt_svcDef2" class="outputTextNB em"> (Scope):</span></label> </div> <div></div> <div Class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:panel_svcDef"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:svcDef" name="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:svcDef" class="inputTextarea" readonly="readonly">Non-medical care, supervision and socialization provided to a functionally impaired adult. Companions may assist or supervise the individual with such tasks as meal preparation, laundry and shopping, but do not perform these activities as discrete services. The provision of companion services does not entail hands-on nursing care. Providers may also perform light housekeeping tasks which are incidental to the care and supervision of the individual. This service is provided in accordance with a therapeutic goal in the plan of care, and is not purely diversional in nature. Companion services may include, but are not limited to, the following activities: (A) escorting an individual to recreational activities or to necessary medical, dental or business appointments; (B) reading to or for an individual; (C) supervising or monitoring an individual during the self-performance of activities of daily living such as meal preparation and consumption, dressing, personal hygiene, laundry and simple household chores; (D) reminding an individual to take self-administered medications; (E) providing monitoring to ensure the safety of an individual; (F) assisting with telephone calls and written communications; and (G) reporting changes in an individual's needs or condition to the supervisor or care manager.</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:lbl_svcLimDscr" for="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:svcLimDscr" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:13: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:13:svapdxC1_1a_prnt:panel_svcLimDscr"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:svcLimDscr" name="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:svcLimDscr" class="inputTextarea" readonly="readonly">Companion Services may not be provided to a participant receiving PCA services. An edit was built into the MMIS to reject any billing for the Companion procedure code if the PCA procedure code is billed. The toal plan of care specifies if both homemaker and companion services are authorized for the participant. The duties of each are defined as part of the overall plan and are not duplicative. This service may not be provided by a relative of the participant.</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:13:svapdxC1_1a_prnt:svcDelMthPtcDir" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:svcDelMthPtcDir" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:lbl_svcDelMthPtcDir" for="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:svcDelMthPtcDir" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:13: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:13:svapdxC1_1a_prnt:svcDelMthPvdrMgd" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:svcDelMthPvdrMgd" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:lbl_svcDelMthPvdrMgd" for="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:svcDelMthPvdrMgd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:13: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:13:svapdxC1_1a_prnt:svcPvdLegResp" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:svcPvdLegResp" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:lbl_svcPvdLegResp" for="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:svcPvdLegResp" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:txt_lbl_svcPvdLegResp" class="outputText">Legally Responsible Person</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:svcPvdRel" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:svcPvdRel" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:lbl_svcPvdRel" for="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:svcPvdRel" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:txt_lbl_svcPvdRel" class="outputText">Relative</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:svcPvdLegGrd" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:svcPvdLegGrd" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:lbl_svcPvdLegGrd" for="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:svcPvdLegGrd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:txt_lbl_svcPvdLegGrd" class="outputText">Legal Guardian</span></label> </div> </div> </div> <div class="pph"> <label id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:lbl_dtProviderTypes" for="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:dtProviderTypes" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:txt_lbl_dtProviderTypes" class="outputText">Provider Specifications:</span></label> </div> <table id="svapdxC1_1_prnt:dtServicesPrnt:13: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:13:svapdxC1_1a_prnt:dtProviderTypes:hdrProvCat" class="outputText">Provider Category</span></th><th scope="col" ><span id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:dtProviderTypes:hdrProvTyp" class="outputText">Provider Type Title</span></th></tr> </thead><tbody > <tr ><td ><input id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypeID" type="text" name="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypeID" value="223182" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypName" class="outputText">Agency</span></td> <td ><span id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:dtProviderTypes:0:pvdTypeName" class="outputText" style="width: 100%;">Provider agency</span></td> </tr> </tbody> </table> <table id="svapdxC1_1_prnt:dtServicesPrnt:13: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:13:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceTypelbl" class="outputText">Service Type: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:13: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:13:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceNamelbl" class="outputText">Service Name: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceName" class="outputText">Companion</span> </div> </div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdCat" for="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdCat" class="outputText">Provider Category:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" name="svapdxC1_1_prnt:dtServicesPrnt:13: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:13:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdTypeName" for="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:13: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:13:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdTypeName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" name="svapdxC1_1_prnt:dtServicesPrnt:13: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:13: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:13:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualLic" for="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualLic1" class="outputText">License </span><span id="svapdxC1_1_prnt:dtServicesPrnt:13: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:13:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualLic"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" name="svapdxC1_1_prnt:dtServicesPrnt:13: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:13:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualCert" for="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualCert1" class="outputText">Certificate </span><span id="svapdxC1_1_prnt:dtServicesPrnt:13: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:13:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualCert"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" name="svapdxC1_1_prnt:dtServicesPrnt:13: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:13:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualOthStd" for="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualOthStd1" class="outputText">Other Standard </span><span id="svapdxC1_1_prnt:dtServicesPrnt:13: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:13:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualOthStd"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" name="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" class="inputTextarea" readonly="readonly">In order to provide companion services and receive reimbursement from the Connecticut Home Care program, Agency must be registered as a provider of Companion Services with the Department of Consumer Protection in the state of CT. The companion employed by the agency shall be at least eighteen (18) years of age, be of good health, have the ability to read, write and follow instructions, be able to report changes in a person's condition or needs to the department, the access agency, or the agency or organization that contracted the persons to perform such functions and shall maintain confidentiality and complete required record-keeping of the employer or contractor of services. Companion services are not licensed or regulated and shall be provided by a person hired by an agency or organization. Relatives of the client cannot be provider of services as defined in section 17b-342-1(b)29) of the Regulations of Connecticut State Agencies. Providers shall demonstrate the ability to meet the needs of the service recipient. The access agency or a department designee shall also ensure that the services provided are appropriate for companion services and are not services which should be provided by a licensed provider of home health services. Companion service agencies or organizations shall abide by the standards and requirements as described in the performing provider agreement and sub-contract with the department or any authorized entity. Any homemaker-companion agency must register with the Department of Consumer Protection pursuant to sections 20-671 to 20-680, inclusive, of the Connecticut General Statutes.</textarea></span> </div> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:13: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:13:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdVrfEnt" for="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:13: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:13:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdVrfEnt"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" name="svapdxC1_1_prnt:dtServicesPrnt:13: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:13:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdVrfFreq" for="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:13: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:13:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdVrfFreq"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" name="svapdxC1_1_prnt:dtServicesPrnt:13:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" class="inputTextarea" readonly="readonly">Upon enrollment as a performing provider and bi-annually 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> <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:14:svapdxC1_1a_prnt:lbl_svcType" for="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:svcType" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:txt_lbl_svcType" class="outputText">Service Type:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:svcType" name="svapdxC1_1_prnt:dtServicesPrnt:14: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:14:svapdxC1_1a_prnt:label1" for="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:svcAltName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:lblUserServiceTitle" class="outputText">Service Title:</span></label> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:panel_svcAltName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:svcAltName" name="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:svcAltName" class="inputTextarea" readonly="readonly">Environmental Accesibility Adaptations</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:14:svapdxC1_1a_prnt:lbl_svcTaxCat1" for="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:svcTaxCat1" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:txt_lbl_svcTaxCat1" class="outputText">Category 1:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:svcTaxCat1" name="svapdxC1_1_prnt:dtServicesPrnt:14: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" selected="selected">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"> </option> </select> </div> <div class="rightCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:lbl_svcTaxSubCat1" for="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:svcTaxSubCat1" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:txt_lbl_svcTaxSubCat1" class="outputText">Sub-Category 1:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:svcTaxSubCat1" name="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:svcTaxSubCat1" class="selectOneMenuLong" size="1" disabled="disabled"> <option value="14010">14010 personal emergency response system (PERS)</option> <option value="14020" selected="selected">14020 home and/or vehicle accessibility adaptations</option> <option value="14031">14031 equipment and technology</option> <option value="14032">14032 supplies</option> <option value="99"> </option> </select> </div> </div> <div class="rowContact"> <div class="leftCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:lbl_taxCat2" for="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:svcTaxCat2" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:txt_lbl_taxCat2" class="outputText">Category 2:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:svcTaxCat2" name="svapdxC1_1_prnt:dtServicesPrnt:14: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:14:svapdxC1_1a_prnt:lbl_taxSubCat2" for="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:svcTaxSubCat2" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:txt_lbl_taxSubCat2" class="outputText">Sub-Category 2:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:svcTaxSubCat2" name="svapdxC1_1_prnt:dtServicesPrnt:14: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:14:svapdxC1_1a_prnt:lbl_taxCat3" for="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:svcTaxCat3" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:txt_lbl_taxCat3" class="outputText">Category 3:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:svcTaxCat3" name="svapdxC1_1_prnt:dtServicesPrnt:14: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:14:svapdxC1_1a_prnt:lbl_taxSubCat3" for="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:svcTaxSubCat3" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:txt_lbl_taxSubCat3" class="outputText">Sub-Category 3:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:svcTaxSubCat3" name="svapdxC1_1_prnt:dtServicesPrnt:14: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:14:svapdxC1_1a_prnt:lbl_taxCat4" for="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:svcTaxCat4" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:txt_lbl_taxCat4" class="outputText">Category 4:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:svcTaxCat4" name="svapdxC1_1_prnt:dtServicesPrnt:14: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:14:svapdxC1_1a_prnt:lbl_taxSubCat4" for="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:svcTaxSubCat4" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:txt_lbl_taxSubCat4" class="outputText">Sub-Category 4:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:svcTaxSubCat4" name="svapdxC1_1_prnt:dtServicesPrnt:14: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:14:svapdxC1_1a_prnt:lbl_svcDef" for="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:svcDef" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:lbl_txt_svcDef1" class="outputText">Service Definition</span><span id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:lbl_txt_svcDef2" class="outputTextNB em"> (Scope):</span></label> </div> <div></div> <div Class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:panel_svcDef"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:svcDef" name="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:svcDef" class="inputTextarea" readonly="readonly">Minor Home Modifications required by the individual's plan of care which are necessary to ensure health, welfare and safety of the individuals to function with greater independence in the home and without which the individual would require institutionalization. Such adaptations may include the installation of hand rails and grab bars in the tub area, widening of doors and installation of ramps. Excluded are those adaptations or improvements to the home which are of general utility and are not of direct medical or remedial benefit to the individual such as carpeting, roof repair or air conditioning. Adaptations which add to the total square footage of the home are excluded from this benefit. All services shall be provided in accordance with applicable state or local building codes. Adaptations are excluded if the residence is owned by someone other than the participant and the adaptations would be the responsibility of the owner/landlord.</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:lbl_svcLimDscr" for="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:svcLimDscr" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:14: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:14:svapdxC1_1a_prnt:panel_svcLimDscr"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:svcLimDscr" name="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:svcLimDscr" class="inputTextarea" readonly="readonly">This service is subject to prior authorization by Department staff.</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:14:svapdxC1_1a_prnt:svcDelMthPtcDir" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:svcDelMthPtcDir" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:lbl_svcDelMthPtcDir" for="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:svcDelMthPtcDir" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:14: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:14:svapdxC1_1a_prnt:svcDelMthPvdrMgd" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:svcDelMthPvdrMgd" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:lbl_svcDelMthPvdrMgd" for="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:svcDelMthPvdrMgd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:14: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:14:svapdxC1_1a_prnt:svcPvdLegResp" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:svcPvdLegResp" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:lbl_svcPvdLegResp" for="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:svcPvdLegResp" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:txt_lbl_svcPvdLegResp" class="outputText">Legally Responsible Person</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:svcPvdRel" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:svcPvdRel" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:lbl_svcPvdRel" for="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:svcPvdRel" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:txt_lbl_svcPvdRel" class="outputText">Relative</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:svcPvdLegGrd" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:svcPvdLegGrd" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:lbl_svcPvdLegGrd" for="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:svcPvdLegGrd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:txt_lbl_svcPvdLegGrd" class="outputText">Legal Guardian</span></label> </div> </div> </div> <div class="pph"> <label id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:lbl_dtProviderTypes" for="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:dtProviderTypes" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:txt_lbl_dtProviderTypes" class="outputText">Provider Specifications:</span></label> </div> <table id="svapdxC1_1_prnt:dtServicesPrnt:14: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:14:svapdxC1_1a_prnt:dtProviderTypes:hdrProvCat" class="outputText">Provider Category</span></th><th scope="col" ><span id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:dtProviderTypes:hdrProvTyp" class="outputText">Provider Type Title</span></th></tr> </thead><tbody > <tr ><td ><input id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypeID" type="text" name="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypeID" value="223132" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypName" class="outputText">Individual</span></td> <td ><span id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:dtProviderTypes:0:pvdTypeName" class="outputText" style="width: 100%;">Non relative able to meet the individual's needs</span></td> </tr> </tbody> </table> <table id="svapdxC1_1_prnt:dtServicesPrnt:14: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:14:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceTypelbl" class="outputText">Service Type: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:14: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:14:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceNamelbl" class="outputText">Service Name: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceName" class="outputText">Environmental Accesibility Adaptations</span> </div> </div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdCat" for="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdCat" class="outputText">Provider Category:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" name="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:dtProviderTypesDetail:0: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:14:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdTypeName" for="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:14: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:14:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdTypeName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" name="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" class="inputTextarea" readonly="readonly">Non relative able to meet the individual's needs</textarea></span> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:14: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:14:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualLic" for="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualLic1" class="outputText">License </span><span id="svapdxC1_1_prnt:dtServicesPrnt:14: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:14:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualLic"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" name="svapdxC1_1_prnt:dtServicesPrnt:14: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:14:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualCert" for="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualCert1" class="outputText">Certificate </span><span id="svapdxC1_1_prnt:dtServicesPrnt:14: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:14:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualCert"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" name="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" class="inputTextarea" readonly="readonly">1. The vendor or contractor shall provide all services, materials, and labor that are necessary to complete the project/minor home modification(s) as indicated. 2. The vendor or contractor must be registered with the Department of Consumer Protection to do business in the State of Connecticut. 3. The vendor or contractor must show evidence of a valid home improvement registration and evidence of workers' compensation (if applicable) and liability insurance, at the time they provide an estimate for the project. 4. If applicable, the vendor or contractor must apply for, obtain, and pay for all permits. All work done shall be done per applicable codes, regulations and standards of construction, including American National Standards Institute (ANSI) standards for barrier-free access and safety requirement. 5. The vendor or contractor shall warranty all work, including labor and materials, for one year from the date of acceptance and thereafter, one year from the date of completion of the project. 6. When equipment is required to make the home accessible, a separate vendor may provide and install the equipment.</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualOthStd" for="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualOthStd1" class="outputText">Other Standard </span><span id="svapdxC1_1_prnt:dtServicesPrnt:14: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:14:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualOthStd"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" name="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" class="inputTextarea" readonly="readonly"></textarea></span> </div> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:14: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:14:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdVrfEnt" for="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:14: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:14:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdVrfEnt"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" name="svapdxC1_1_prnt:dtServicesPrnt:14: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:14:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdVrfFreq" for="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:14: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:14:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdVrfFreq"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" name="svapdxC1_1_prnt:dtServicesPrnt:14:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" class="inputTextarea" readonly="readonly">prior to the provision of service</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:15:svapdxC1_1a_prnt:lbl_svcType" for="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:svcType" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:txt_lbl_svcType" class="outputText">Service Type:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:svcType" name="svapdxC1_1_prnt:dtServicesPrnt:15: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:15:svapdxC1_1a_prnt:label1" for="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:svcAltName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:lblUserServiceTitle" class="outputText">Service Title:</span></label> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:panel_svcAltName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:svcAltName" name="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:svcAltName" class="inputTextarea" readonly="readonly">Home Delivered Meals</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:15:svapdxC1_1a_prnt:lbl_svcTaxCat1" for="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:svcTaxCat1" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:txt_lbl_svcTaxCat1" class="outputText">Category 1:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:svcTaxCat1" name="svapdxC1_1_prnt:dtServicesPrnt:15: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" selected="selected">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"> </option> </select> </div> <div class="rightCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:lbl_svcTaxSubCat1" for="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:svcTaxSubCat1" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:txt_lbl_svcTaxSubCat1" class="outputText">Sub-Category 1:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:svcTaxSubCat1" name="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:svcTaxSubCat1" class="selectOneMenuLong" size="1" disabled="disabled"> <option value="06010" selected="selected">06010 home delivered meals</option> <option value="99"> </option> </select> </div> </div> <div class="rowContact"> <div class="leftCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:lbl_taxCat2" for="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:svcTaxCat2" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:txt_lbl_taxCat2" class="outputText">Category 2:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:svcTaxCat2" name="svapdxC1_1_prnt:dtServicesPrnt:15: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:15:svapdxC1_1a_prnt:lbl_taxSubCat2" for="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:svcTaxSubCat2" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:txt_lbl_taxSubCat2" class="outputText">Sub-Category 2:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:svcTaxSubCat2" name="svapdxC1_1_prnt:dtServicesPrnt:15: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:15:svapdxC1_1a_prnt:lbl_taxCat3" for="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:svcTaxCat3" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:txt_lbl_taxCat3" class="outputText">Category 3:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:svcTaxCat3" name="svapdxC1_1_prnt:dtServicesPrnt:15: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:15:svapdxC1_1a_prnt:lbl_taxSubCat3" for="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:svcTaxSubCat3" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:txt_lbl_taxSubCat3" class="outputText">Sub-Category 3:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:svcTaxSubCat3" name="svapdxC1_1_prnt:dtServicesPrnt:15: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:15:svapdxC1_1a_prnt:lbl_taxCat4" for="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:svcTaxCat4" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:txt_lbl_taxCat4" class="outputText">Category 4:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:svcTaxCat4" name="svapdxC1_1_prnt:dtServicesPrnt:15: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:15:svapdxC1_1a_prnt:lbl_taxSubCat4" for="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:svcTaxSubCat4" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:txt_lbl_taxSubCat4" class="outputText">Sub-Category 4:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:svcTaxSubCat4" name="svapdxC1_1_prnt:dtServicesPrnt:15: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:15:svapdxC1_1a_prnt:lbl_svcDef" for="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:svcDef" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:lbl_txt_svcDef1" class="outputText">Service Definition</span><span id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:lbl_txt_svcDef2" class="outputTextNB em"> (Scope):</span></label> </div> <div></div> <div Class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:panel_svcDef"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:svcDef" name="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:svcDef" class="inputTextarea" readonly="readonly">Home delivered meals, or "meals on wheels," include the preparation and delivery of one or two meals for persons who are unable to prepare or obtain nourishing meals on their own. Meals on Wheels providers include delicatessens, Family Services Agencies, Community Action Agencies, Catholic Charities, Town Social Services, visiting nurse agencies, assisted living agencies, senior centers, and soup kitchens. Meals must meet a minimum of one-third for single meals and two-thirds for double meals of the daily recommended allowance and requirements as established by the Food and Nutrition Academy of Sciences National Reasearch Council. Special diet meals are available such as diabetic, cardiac,low sodium and renal as are ethnic meals such as Hispanic and Kosher meals. Liquid supplements, such as Ensure, are generally unavailable as the home delivered meals. There is one Community Action Agency in Northwest CT that provides liquid supplement meal replacement.</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:lbl_svcLimDscr" for="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:svcLimDscr" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:15: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:15:svapdxC1_1a_prnt:panel_svcLimDscr"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:svcLimDscr" name="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:svcLimDscr" class="inputTextarea" readonly="readonly">No more than two meals per day up to seven times per week as specified in the individual service plan. Liquid supplements are covered by the CT Medicaid program with prior authorization for clients who are tube fed.</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:15:svapdxC1_1a_prnt:svcDelMthPtcDir" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:svcDelMthPtcDir" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:lbl_svcDelMthPtcDir" for="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:svcDelMthPtcDir" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:15: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:15:svapdxC1_1a_prnt:svcDelMthPvdrMgd" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:svcDelMthPvdrMgd" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:lbl_svcDelMthPvdrMgd" for="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:svcDelMthPvdrMgd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:15: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:15:svapdxC1_1a_prnt:svcPvdLegResp" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:svcPvdLegResp" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:lbl_svcPvdLegResp" for="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:svcPvdLegResp" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:txt_lbl_svcPvdLegResp" class="outputText">Legally Responsible Person</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:svcPvdRel" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:svcPvdRel" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:lbl_svcPvdRel" for="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:svcPvdRel" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:txt_lbl_svcPvdRel" class="outputText">Relative</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:svcPvdLegGrd" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:svcPvdLegGrd" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:lbl_svcPvdLegGrd" for="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:svcPvdLegGrd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:txt_lbl_svcPvdLegGrd" class="outputText">Legal Guardian</span></label> </div> </div> </div> <div class="pph"> <label id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:lbl_dtProviderTypes" for="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:dtProviderTypes" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:txt_lbl_dtProviderTypes" class="outputText">Provider Specifications:</span></label> </div> <table id="svapdxC1_1_prnt:dtServicesPrnt:15: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:15:svapdxC1_1a_prnt:dtProviderTypes:hdrProvCat" class="outputText">Provider Category</span></th><th scope="col" ><span id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:dtProviderTypes:hdrProvTyp" class="outputText">Provider Type Title</span></th></tr> </thead><tbody > <tr ><td ><input id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypeID" type="text" name="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypeID" value="223117" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypName" class="outputText">Agency</span></td> <td ><span id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:dtProviderTypes:0:pvdTypeName" class="outputText" style="width: 100%;">Home Delivered Meals Providers</span></td> </tr> </tbody> </table> <table id="svapdxC1_1_prnt:dtServicesPrnt:15: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:15:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceTypelbl" class="outputText">Service Type: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:15: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:15:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceNamelbl" class="outputText">Service Name: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceName" class="outputText">Home Delivered Meals</span> </div> </div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdCat" for="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdCat" class="outputText">Provider Category:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" name="svapdxC1_1_prnt:dtServicesPrnt:15: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:15:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdTypeName" for="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:15: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:15:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdTypeName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" name="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" class="inputTextarea" readonly="readonly">Home Delivered Meals Providers</textarea></span> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:15: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:15:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualLic" for="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualLic1" class="outputText">License </span><span id="svapdxC1_1_prnt:dtServicesPrnt:15: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:15:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualLic"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" name="svapdxC1_1_prnt:dtServicesPrnt:15: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:15:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualCert" for="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualCert1" class="outputText">Certificate </span><span id="svapdxC1_1_prnt:dtServicesPrnt:15: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:15:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualCert"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" name="svapdxC1_1_prnt:dtServicesPrnt:15: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:15:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualOthStd" for="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualOthStd1" class="outputText">Other Standard </span><span id="svapdxC1_1_prnt:dtServicesPrnt:15: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:15:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualOthStd"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" name="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" class="inputTextarea" readonly="readonly">Reimbursment for home delivered meals shall be available under the waiver only to providers which provide meals that meet a minimum of one-third of the current daily recommended dietary allowance and requirements as established by the Food and Nutrition Board of the National Academy of Sciences National Research Council. All “meals on wheels” providers shall provide their menus to the department, contracted agencies or department designee for review and approval. Quality assurance and quality control shall be performed by the department'’s contracted providers to ensure that the “meals on wheels” service providers are in compliance with the dietary requirements and the requirements for the preparation and storage and delivery of food based on the department policies for the elderly nutrition program and Title III of the Older American’s Act.</textarea></span> </div> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:15: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:15:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdVrfEnt" for="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:15: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:15:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdVrfEnt"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" name="svapdxC1_1_prnt:dtServicesPrnt:15: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:15:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdVrfFreq" for="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:15: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:15:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdVrfFreq"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" name="svapdxC1_1_prnt:dtServicesPrnt:15:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" class="inputTextarea" readonly="readonly">at the time of enrollment as a provider 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> <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:16:svapdxC1_1a_prnt:lbl_svcType" for="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:svcType" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:txt_lbl_svcType" class="outputText">Service Type:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:svcType" name="svapdxC1_1_prnt:dtServicesPrnt:16: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:16:svapdxC1_1a_prnt:label1" for="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:svcAltName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:lblUserServiceTitle" class="outputText">Service Title:</span></label> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:panel_svcAltName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:svcAltName" name="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:svcAltName" class="inputTextarea" readonly="readonly">Mental Health Counseling</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:16:svapdxC1_1a_prnt:lbl_svcTaxCat1" for="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:svcTaxCat1" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:txt_lbl_svcTaxCat1" class="outputText">Category 1:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:svcTaxCat1" name="svapdxC1_1_prnt:dtServicesPrnt:16: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" selected="selected">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"> </option> </select> </div> <div class="rightCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:lbl_svcTaxSubCat1" for="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:svcTaxSubCat1" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:txt_lbl_svcTaxSubCat1" class="outputText">Sub-Category 1:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:svcTaxSubCat1" name="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:svcTaxSubCat1" class="selectOneMenuLong" size="1" disabled="disabled"> <option value="10010">10010 mental health assessment</option> <option value="10020">10020 assertive community treatment</option> <option value="10030">10030 crisis intervention</option> <option value="10040">10040 behavior support</option> <option value="10050">10050 peer specialist</option> <option value="10060" selected="selected">10060 counseling</option> <option value="10070">10070 psychosocial rehabilitation</option> <option value="10080">10080 clinic services</option> <option value="10090">10090 other mental health and behavioral services</option> <option value="99"> </option> </select> </div> </div> <div class="rowContact"> <div class="leftCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:lbl_taxCat2" for="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:svcTaxCat2" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:txt_lbl_taxCat2" class="outputText">Category 2:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:svcTaxCat2" name="svapdxC1_1_prnt:dtServicesPrnt:16: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:16:svapdxC1_1a_prnt:lbl_taxSubCat2" for="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:svcTaxSubCat2" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:txt_lbl_taxSubCat2" class="outputText">Sub-Category 2:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:svcTaxSubCat2" name="svapdxC1_1_prnt:dtServicesPrnt:16: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:16:svapdxC1_1a_prnt:lbl_taxCat3" for="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:svcTaxCat3" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:txt_lbl_taxCat3" class="outputText">Category 3:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:svcTaxCat3" name="svapdxC1_1_prnt:dtServicesPrnt:16: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:16:svapdxC1_1a_prnt:lbl_taxSubCat3" for="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:svcTaxSubCat3" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:txt_lbl_taxSubCat3" class="outputText">Sub-Category 3:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:svcTaxSubCat3" name="svapdxC1_1_prnt:dtServicesPrnt:16: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:16:svapdxC1_1a_prnt:lbl_taxCat4" for="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:svcTaxCat4" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:txt_lbl_taxCat4" class="outputText">Category 4:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:svcTaxCat4" name="svapdxC1_1_prnt:dtServicesPrnt:16: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:16:svapdxC1_1a_prnt:lbl_taxSubCat4" for="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:svcTaxSubCat4" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:txt_lbl_taxSubCat4" class="outputText">Sub-Category 4:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:svcTaxSubCat4" name="svapdxC1_1_prnt:dtServicesPrnt:16: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:16:svapdxC1_1a_prnt:lbl_svcDef" for="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:svcDef" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:lbl_txt_svcDef1" class="outputText">Service Definition</span><span id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:lbl_txt_svcDef2" class="outputTextNB em"> (Scope):</span></label> </div> <div></div> <div Class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:panel_svcDef"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:svcDef" name="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:svcDef" class="inputTextarea" readonly="readonly">Mental Health Counseling Services are professional counseling services provided to help resolve or enable the eligible individual to cope with individual, family, and/or environmentally related problems and conditions. Counseling focuses on issues such as problems in maintaining a home in the community, relocation within the community, dealing with long term disability, substance abuse, and family relationships. The department shall pay for mental health services conforming to accepted methods of diagnosis and treatment, including: (A) mental health evaluation and assessment; (B) individual counseling; (C) group counseling; and (D) family counseling. Mental Health Counseling can be provided in the client'’s home or location best suited for the client.</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:lbl_svcLimDscr" for="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:svcLimDscr" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:16: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:16:svapdxC1_1a_prnt:panel_svcLimDscr"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:svcLimDscr" name="svapdxC1_1_prnt:dtServicesPrnt:16: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:16:svapdxC1_1a_prnt:svcDelMthPtcDir" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:svcDelMthPtcDir" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:lbl_svcDelMthPtcDir" for="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:svcDelMthPtcDir" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:16: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:16:svapdxC1_1a_prnt:svcDelMthPvdrMgd" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:svcDelMthPvdrMgd" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:lbl_svcDelMthPvdrMgd" for="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:svcDelMthPvdrMgd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:16: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:16:svapdxC1_1a_prnt:svcPvdLegResp" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:svcPvdLegResp" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:lbl_svcPvdLegResp" for="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:svcPvdLegResp" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:txt_lbl_svcPvdLegResp" class="outputText">Legally Responsible Person</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:svcPvdRel" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:svcPvdRel" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:lbl_svcPvdRel" for="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:svcPvdRel" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:txt_lbl_svcPvdRel" class="outputText">Relative</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:svcPvdLegGrd" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:svcPvdLegGrd" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:lbl_svcPvdLegGrd" for="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:svcPvdLegGrd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:txt_lbl_svcPvdLegGrd" class="outputText">Legal Guardian</span></label> </div> </div> </div> <div class="pph"> <label id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:lbl_dtProviderTypes" for="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:dtProviderTypes" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:txt_lbl_dtProviderTypes" class="outputText">Provider Specifications:</span></label> </div> <table id="svapdxC1_1_prnt:dtServicesPrnt:16: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:16:svapdxC1_1a_prnt:dtProviderTypes:hdrProvCat" class="outputText">Provider Category</span></th><th scope="col" ><span id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:dtProviderTypes:hdrProvTyp" class="outputText">Provider Type Title</span></th></tr> </thead><tbody > <tr ><td ><input id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypeID" type="text" name="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypeID" value="223200" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypName" class="outputText">Individual</span></td> <td ><span id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:dtProviderTypes:0:pvdTypeName" class="outputText" style="width: 100%;">Masters Level or Licensed Social Worker or Counselor</span></td> </tr> </tbody> </table> <table id="svapdxC1_1_prnt:dtServicesPrnt:16: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:16:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceTypelbl" class="outputText">Service Type: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:16: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:16:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceNamelbl" class="outputText">Service Name: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceName" class="outputText">Mental Health Counseling</span> </div> </div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdCat" for="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdCat" class="outputText">Provider Category:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" name="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:dtProviderTypesDetail:0: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:16:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdTypeName" for="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:16: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:16:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdTypeName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" name="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" class="inputTextarea" readonly="readonly">Masters Level or Licensed Social Worker or Counselor</textarea></span> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:16: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:16:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualLic" for="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualLic1" class="outputText">License </span><span id="svapdxC1_1_prnt:dtServicesPrnt:16: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:16:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualLic"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" name="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" class="inputTextarea" readonly="readonly">For purposes of receiving reimbursement under the Connecticut Home Care Program, a mental health counseling provider shall be a licensed independent social worker as defined in Connecticut General Statutes 20-195m or a Licensed Professional Councelor as defined in section 20-195aa of the Connecticut General Statutes, and shall have experience and training in providing mental health services to the elderly.</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualCert" for="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualCert1" class="outputText">Certificate </span><span id="svapdxC1_1_prnt:dtServicesPrnt:16: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:16:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualCert"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" name="svapdxC1_1_prnt:dtServicesPrnt:16: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:16:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualOthStd" for="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualOthStd1" class="outputText">Other Standard </span><span id="svapdxC1_1_prnt:dtServicesPrnt:16: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:16:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualOthStd"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" name="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" class="inputTextarea" readonly="readonly">A social worker who holds a masters degree from an accredited school of social work, or an individual who has a masters degree in counseling, psychology or psychiatric nursing and has experience in providing mental health services to the elderly may also provide mental health counceling.</textarea></span> </div> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:16: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:16:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdVrfEnt" for="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:16: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:16:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdVrfEnt"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" name="svapdxC1_1_prnt:dtServicesPrnt:16: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:16:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdVrfFreq" for="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:16: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:16:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdVrfFreq"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" name="svapdxC1_1_prnt:dtServicesPrnt:16:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" class="inputTextarea" readonly="readonly">At time of enrollment as a performing provider and bi-annually 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> <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:17:svapdxC1_1a_prnt:lbl_svcType" for="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:svcType" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:txt_lbl_svcType" class="outputText">Service Type:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:svcType" name="svapdxC1_1_prnt:dtServicesPrnt:17: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:17:svapdxC1_1a_prnt:label1" for="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:svcAltName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:lblUserServiceTitle" class="outputText">Service Title:</span></label> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:panel_svcAltName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:svcAltName" name="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:svcAltName" class="inputTextarea" readonly="readonly">Personal Emergency Response Systems</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:17:svapdxC1_1a_prnt:lbl_svcTaxCat1" for="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:svcTaxCat1" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:txt_lbl_svcTaxCat1" class="outputText">Category 1:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:svcTaxCat1" name="svapdxC1_1_prnt:dtServicesPrnt:17: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" selected="selected">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"> </option> </select> </div> <div class="rightCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:lbl_svcTaxSubCat1" for="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:svcTaxSubCat1" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:txt_lbl_svcTaxSubCat1" class="outputText">Sub-Category 1:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:svcTaxSubCat1" name="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:svcTaxSubCat1" class="selectOneMenuLong" size="1" disabled="disabled"> <option value="14010" selected="selected">14010 personal emergency response system (PERS)</option> <option value="14020">14020 home and/or vehicle accessibility adaptations</option> <option value="14031">14031 equipment and technology</option> <option value="14032">14032 supplies</option> <option value="99"> </option> </select> </div> </div> <div class="rowContact"> <div class="leftCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:lbl_taxCat2" for="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:svcTaxCat2" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:txt_lbl_taxCat2" class="outputText">Category 2:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:svcTaxCat2" name="svapdxC1_1_prnt:dtServicesPrnt:17: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:17:svapdxC1_1a_prnt:lbl_taxSubCat2" for="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:svcTaxSubCat2" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:txt_lbl_taxSubCat2" class="outputText">Sub-Category 2:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:svcTaxSubCat2" name="svapdxC1_1_prnt:dtServicesPrnt:17: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:17:svapdxC1_1a_prnt:lbl_taxCat3" for="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:svcTaxCat3" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:txt_lbl_taxCat3" class="outputText">Category 3:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:svcTaxCat3" name="svapdxC1_1_prnt:dtServicesPrnt:17: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:17:svapdxC1_1a_prnt:lbl_taxSubCat3" for="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:svcTaxSubCat3" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:txt_lbl_taxSubCat3" class="outputText">Sub-Category 3:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:svcTaxSubCat3" name="svapdxC1_1_prnt:dtServicesPrnt:17: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:17:svapdxC1_1a_prnt:lbl_taxCat4" for="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:svcTaxCat4" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:txt_lbl_taxCat4" class="outputText">Category 4:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:svcTaxCat4" name="svapdxC1_1_prnt:dtServicesPrnt:17: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:17:svapdxC1_1a_prnt:lbl_taxSubCat4" for="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:svcTaxSubCat4" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:txt_lbl_taxSubCat4" class="outputText">Sub-Category 4:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:svcTaxSubCat4" name="svapdxC1_1_prnt:dtServicesPrnt:17: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:17:svapdxC1_1a_prnt:lbl_svcDef" for="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:svcDef" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:lbl_txt_svcDef1" class="outputText">Service Definition</span><span id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:lbl_txt_svcDef2" class="outputTextNB em"> (Scope):</span></label> </div> <div></div> <div Class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:panel_svcDef"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:svcDef" name="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:svcDef" class="inputTextarea" readonly="readonly">PERS is an electronic device which enables certain individuals at high risk of institutionalization to secure help in an emergency. The individual may also wear a portable "help" button to allow for mobility. The system is connected to the person's phone and programmed to signal a response center once a "help" button is activated. The response center is staffed by trained professionals 24/7. PERS services are limited to those individuals who live alone, or who are alone for significant parts of the day, and have no regular caregiver for extended periods of time, and who would otherwise require extensive routine supervision. Installation, upkeep and maintenance of the device is provided.</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:lbl_svcLimDscr" for="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:svcLimDscr" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:17: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:17:svapdxC1_1a_prnt:panel_svcLimDscr"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:svcLimDscr" name="svapdxC1_1_prnt:dtServicesPrnt:17: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:17:svapdxC1_1a_prnt:svcDelMthPtcDir" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:svcDelMthPtcDir" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:lbl_svcDelMthPtcDir" for="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:svcDelMthPtcDir" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:17: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:17:svapdxC1_1a_prnt:svcDelMthPvdrMgd" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:svcDelMthPvdrMgd" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:lbl_svcDelMthPvdrMgd" for="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:svcDelMthPvdrMgd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:17: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:17:svapdxC1_1a_prnt:svcPvdLegResp" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:svcPvdLegResp" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:lbl_svcPvdLegResp" for="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:svcPvdLegResp" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:txt_lbl_svcPvdLegResp" class="outputText">Legally Responsible Person</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:svcPvdRel" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:svcPvdRel" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:lbl_svcPvdRel" for="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:svcPvdRel" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:txt_lbl_svcPvdRel" class="outputText">Relative</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:svcPvdLegGrd" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:svcPvdLegGrd" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:lbl_svcPvdLegGrd" for="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:svcPvdLegGrd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:txt_lbl_svcPvdLegGrd" class="outputText">Legal Guardian</span></label> </div> </div> </div> <div class="pph"> <label id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:lbl_dtProviderTypes" for="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:dtProviderTypes" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:txt_lbl_dtProviderTypes" class="outputText">Provider Specifications:</span></label> </div> <table id="svapdxC1_1_prnt:dtServicesPrnt:17: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:17:svapdxC1_1a_prnt:dtProviderTypes:hdrProvCat" class="outputText">Provider Category</span></th><th scope="col" ><span id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:dtProviderTypes:hdrProvTyp" class="outputText">Provider Type Title</span></th></tr> </thead><tbody > <tr ><td ><input id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypeID" type="text" name="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypeID" value="223098" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypName" class="outputText">Agency</span></td> <td ><span id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:dtProviderTypes:0:pvdTypeName" class="outputText" style="width: 100%;">Vendors who sell and install appropriate PERS equipment</span></td> </tr> </tbody> </table> <table id="svapdxC1_1_prnt:dtServicesPrnt:17: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:17:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceTypelbl" class="outputText">Service Type: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:17: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:17:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceNamelbl" class="outputText">Service Name: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceName" class="outputText">Personal Emergency Response Systems</span> </div> </div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdCat" for="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdCat" class="outputText">Provider Category:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" name="svapdxC1_1_prnt:dtServicesPrnt:17: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:17:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdTypeName" for="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:17: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:17:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdTypeName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" name="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" class="inputTextarea" readonly="readonly">Vendors who sell and install appropriate PERS equipment</textarea></span> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:17: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:17:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualLic" for="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualLic1" class="outputText">License </span><span id="svapdxC1_1_prnt:dtServicesPrnt:17: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:17:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualLic"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" name="svapdxC1_1_prnt:dtServicesPrnt:17: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:17:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualCert" for="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualCert1" class="outputText">Certificate </span><span id="svapdxC1_1_prnt:dtServicesPrnt:17: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:17:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualCert"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" name="svapdxC1_1_prnt:dtServicesPrnt:17: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:17:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualOthStd" for="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualOthStd1" class="outputText">Other Standard </span><span id="svapdxC1_1_prnt:dtServicesPrnt:17: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:17:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualOthStd"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" name="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" class="inputTextarea" readonly="readonly">Vendor that has an approved contract through DSS</textarea></span> </div> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:17: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:17:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdVrfEnt" for="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:17: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:17:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdVrfEnt"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" name="svapdxC1_1_prnt:dtServicesPrnt:17: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:17:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdVrfFreq" for="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:17: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:17:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdVrfFreq"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" name="svapdxC1_1_prnt:dtServicesPrnt:17:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" class="inputTextarea" readonly="readonly">At the initiation of the contract 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> <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:18:svapdxC1_1a_prnt:lbl_svcType" for="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:svcType" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:txt_lbl_svcType" class="outputText">Service Type:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:svcType" name="svapdxC1_1_prnt:dtServicesPrnt:18: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:18:svapdxC1_1a_prnt:label1" for="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:svcAltName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:lblUserServiceTitle" class="outputText">Service Title:</span></label> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:panel_svcAltName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:svcAltName" name="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:svcAltName" class="inputTextarea" readonly="readonly">Recovery Assistant</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:18:svapdxC1_1a_prnt:lbl_svcTaxCat1" for="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:svcTaxCat1" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:txt_lbl_svcTaxCat1" class="outputText">Category 1:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:svcTaxCat1" name="svapdxC1_1_prnt:dtServicesPrnt:18: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" selected="selected">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"> </option> </select> </div> <div class="rightCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:lbl_svcTaxSubCat1" for="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:svcTaxSubCat1" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:txt_lbl_svcTaxSubCat1" class="outputText">Sub-Category 1:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:svcTaxSubCat1" name="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:svcTaxSubCat1" class="selectOneMenuLong" size="1" disabled="disabled"> <option value="08010">08010 home-based habilitation</option> <option value="08020">08020 home health aide</option> <option value="08030" selected="selected">08030 personal care</option> <option value="08040">08040 companion</option> <option value="08050">08050 homemaker</option> <option value="08060">08060 chore</option> <option value="99"> </option> </select> </div> </div> <div class="rowContact"> <div class="leftCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:lbl_taxCat2" for="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:svcTaxCat2" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:txt_lbl_taxCat2" class="outputText">Category 2:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:svcTaxCat2" name="svapdxC1_1_prnt:dtServicesPrnt:18: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:18:svapdxC1_1a_prnt:lbl_taxSubCat2" for="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:svcTaxSubCat2" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:txt_lbl_taxSubCat2" class="outputText">Sub-Category 2:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:svcTaxSubCat2" name="svapdxC1_1_prnt:dtServicesPrnt:18: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:18:svapdxC1_1a_prnt:lbl_taxCat3" for="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:svcTaxCat3" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:txt_lbl_taxCat3" class="outputText">Category 3:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:svcTaxCat3" name="svapdxC1_1_prnt:dtServicesPrnt:18: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:18:svapdxC1_1a_prnt:lbl_taxSubCat3" for="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:svcTaxSubCat3" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:txt_lbl_taxSubCat3" class="outputText">Sub-Category 3:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:svcTaxSubCat3" name="svapdxC1_1_prnt:dtServicesPrnt:18: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:18:svapdxC1_1a_prnt:lbl_taxCat4" for="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:svcTaxCat4" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:txt_lbl_taxCat4" class="outputText">Category 4:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:svcTaxCat4" name="svapdxC1_1_prnt:dtServicesPrnt:18: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:18:svapdxC1_1a_prnt:lbl_taxSubCat4" for="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:svcTaxSubCat4" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:txt_lbl_taxSubCat4" class="outputText">Sub-Category 4:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:svcTaxSubCat4" name="svapdxC1_1_prnt:dtServicesPrnt:18: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:18:svapdxC1_1a_prnt:lbl_svcDef" for="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:svcDef" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:lbl_txt_svcDef1" class="outputText">Service Definition</span><span id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:lbl_txt_svcDef2" class="outputTextNB em"> (Scope):</span></label> </div> <div></div> <div Class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:panel_svcDef"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:svcDef" name="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:svcDef" class="inputTextarea" readonly="readonly">A flexible range of supportive assistance provided face-to-face in accordance with a Waiver, the service that enables a participant to maintain a home/apartment, encourages the use of existing natural supports, and fosters involvement in social and community activities. Service activities include: performing household tasks, providing instructive assistance, or cuing to prompt the participant to carry out tasks (e.g., meal preparation; routine household chores, cleaning, laundry, shopping, and bill-paying; and participation in social and recreational activities), and providing supportive companionship. The Recovery Assistant may also provide instruction or cuing to prompt the participant to dress appropriately and perform basic hygiene functions; supportive assistance and supervision of the participant; and short-term relief in the home for a participant who is unable to care for himself/herself when the primary caregiver is absent or in need of relief. The Recovery Assistant service is provided to persons with a mental health or substance abuse diagnosis.</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:lbl_svcLimDscr" for="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:svcLimDscr" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:18: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:18:svapdxC1_1a_prnt:panel_svcLimDscr"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:svcLimDscr" name="svapdxC1_1_prnt:dtServicesPrnt:18: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:18:svapdxC1_1a_prnt:svcDelMthPtcDir" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:svcDelMthPtcDir" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:lbl_svcDelMthPtcDir" for="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:svcDelMthPtcDir" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:18: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:18:svapdxC1_1a_prnt:svcDelMthPvdrMgd" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:svcDelMthPvdrMgd" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:lbl_svcDelMthPvdrMgd" for="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:svcDelMthPvdrMgd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:18: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:18:svapdxC1_1a_prnt:svcPvdLegResp" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:svcPvdLegResp" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:lbl_svcPvdLegResp" for="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:svcPvdLegResp" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:txt_lbl_svcPvdLegResp" class="outputText">Legally Responsible Person</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:svcPvdRel" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:svcPvdRel" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:lbl_svcPvdRel" for="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:svcPvdRel" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:txt_lbl_svcPvdRel" class="outputText">Relative</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:svcPvdLegGrd" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:svcPvdLegGrd" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:lbl_svcPvdLegGrd" for="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:svcPvdLegGrd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:txt_lbl_svcPvdLegGrd" class="outputText">Legal Guardian</span></label> </div> </div> </div> <div class="pph"> <label id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:lbl_dtProviderTypes" for="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:dtProviderTypes" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:txt_lbl_dtProviderTypes" class="outputText">Provider Specifications:</span></label> </div> <table id="svapdxC1_1_prnt:dtServicesPrnt:18: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:18:svapdxC1_1a_prnt:dtProviderTypes:hdrProvCat" class="outputText">Provider Category</span></th><th scope="col" ><span id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:dtProviderTypes:hdrProvTyp" class="outputText">Provider Type Title</span></th></tr> </thead><tbody > <tr ><td ><input id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypeID" type="text" name="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypeID" value="225400" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypName" class="outputText">Agency</span></td> <td ><span id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:dtProviderTypes:0:pvdTypeName" class="outputText" style="width: 100%;">Provider Agency</span></td> </tr> </tbody> </table> <table id="svapdxC1_1_prnt:dtServicesPrnt:18: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:18:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceTypelbl" class="outputText">Service Type: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:18: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:18:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceNamelbl" class="outputText">Service Name: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceName" class="outputText">Recovery Assistant</span> </div> </div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdCat" for="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdCat" class="outputText">Provider Category:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" name="svapdxC1_1_prnt:dtServicesPrnt:18: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:18:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdTypeName" for="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:18: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:18:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdTypeName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" name="svapdxC1_1_prnt:dtServicesPrnt:18: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:18: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:18:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualLic" for="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualLic1" class="outputText">License </span><span id="svapdxC1_1_prnt:dtServicesPrnt:18: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:18:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualLic"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" name="svapdxC1_1_prnt:dtServicesPrnt:18: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:18:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualCert" for="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualCert1" class="outputText">Certificate </span><span id="svapdxC1_1_prnt:dtServicesPrnt:18: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:18:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualCert"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" name="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" class="inputTextarea" readonly="readonly">Recovery Assistant must have certification from the Dept. of Mental Health and Addiction Services in order to be a provider of this service.</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualOthStd" for="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualOthStd1" class="outputText">Other Standard </span><span id="svapdxC1_1_prnt:dtServicesPrnt:18: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:18:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualOthStd"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" name="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" class="inputTextarea" readonly="readonly"></textarea></span> </div> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:18: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:18:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdVrfEnt" for="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:18: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:18:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdVrfEnt"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" name="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" class="inputTextarea" readonly="readonly">Fiscal intermediary and provider agency</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdVrfFreq" for="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:18: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:18:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdVrfFreq"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" name="svapdxC1_1_prnt:dtServicesPrnt:18:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" class="inputTextarea" readonly="readonly">At the time of employment and every two 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> </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:19:svapdxC1_1a_prnt:lbl_svcType" for="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:svcType" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:txt_lbl_svcType" class="outputText">Service Type:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:svcType" name="svapdxC1_1_prnt:dtServicesPrnt:19: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:19:svapdxC1_1a_prnt:label1" for="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:svcAltName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:lblUserServiceTitle" class="outputText">Service Title:</span></label> <div></div> <div class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:panel_svcAltName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:svcAltName" name="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:svcAltName" class="inputTextarea" readonly="readonly">Transportation</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:19:svapdxC1_1a_prnt:lbl_svcTaxCat1" for="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:svcTaxCat1" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:txt_lbl_svcTaxCat1" class="outputText">Category 1:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:svcTaxCat1" name="svapdxC1_1_prnt:dtServicesPrnt:19: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" selected="selected">15 Non-Medical Transportation</option> <option value="16">16 Community Transition Services</option> <option value="17">17 Other Services</option> <option value="99"> </option> </select> </div> <div class="rightCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:lbl_svcTaxSubCat1" for="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:svcTaxSubCat1" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:txt_lbl_svcTaxSubCat1" class="outputText">Sub-Category 1:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:svcTaxSubCat1" name="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:svcTaxSubCat1" class="selectOneMenuLong" size="1" disabled="disabled"> <option value="15010" selected="selected">15010 non-medical transportation</option> <option value="99"> </option> </select> </div> </div> <div class="rowContact"> <div class="leftCol50 pageOneLabel"> <p> <label id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:lbl_taxCat2" for="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:svcTaxCat2" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:txt_lbl_taxCat2" class="outputText">Category 2:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:svcTaxCat2" name="svapdxC1_1_prnt:dtServicesPrnt:19: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:19:svapdxC1_1a_prnt:lbl_taxSubCat2" for="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:svcTaxSubCat2" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:txt_lbl_taxSubCat2" class="outputText">Sub-Category 2:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:svcTaxSubCat2" name="svapdxC1_1_prnt:dtServicesPrnt:19: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:19:svapdxC1_1a_prnt:lbl_taxCat3" for="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:svcTaxCat3" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:txt_lbl_taxCat3" class="outputText">Category 3:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:svcTaxCat3" name="svapdxC1_1_prnt:dtServicesPrnt:19: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:19:svapdxC1_1a_prnt:lbl_taxSubCat3" for="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:svcTaxSubCat3" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:txt_lbl_taxSubCat3" class="outputText">Sub-Category 3:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:svcTaxSubCat3" name="svapdxC1_1_prnt:dtServicesPrnt:19: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:19:svapdxC1_1a_prnt:lbl_taxCat4" for="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:svcTaxCat4" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:txt_lbl_taxCat4" class="outputText">Category 4:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:svcTaxCat4" name="svapdxC1_1_prnt:dtServicesPrnt:19: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:19:svapdxC1_1a_prnt:lbl_taxSubCat4" for="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:svcTaxSubCat4" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:txt_lbl_taxSubCat4" class="outputText">Sub-Category 4:</span></label> </p> <select id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:svcTaxSubCat4" name="svapdxC1_1_prnt:dtServicesPrnt:19: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:19:svapdxC1_1a_prnt:lbl_svcDef" for="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:svcDef" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:lbl_txt_svcDef1" class="outputText">Service Definition</span><span id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:lbl_txt_svcDef2" class="outputTextNB em"> (Scope):</span></label> </div> <div></div> <div Class="inputTextareaWA"> <span id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:panel_svcDef"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:svcDef" name="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:svcDef" class="inputTextarea" readonly="readonly">Transportation services provide access to social services, community services and appropriate social or recreational facilities that are essential to help some individuals avoid institutionalization by enabling these individuals to retain their role as community members. This service is offered in addition to medical transportation offered under the state plan and shall not replace it. (A) These services are provided when transportation is required to promote and enhance independent living and self-support; and (B) Transportation services may be provided by taxi, livery, bus, invalid coach, volunteer organization or individuals. They shall be reimbursed when they are necessary to provide access to needed community based services or community activities as specified in the approved plan of care.</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:lbl_svcLimDscr" for="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:svcLimDscr" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:19: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:19:svapdxC1_1a_prnt:panel_svcLimDscr"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:svcLimDscr" name="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:svcLimDscr" class="inputTextarea" readonly="readonly">Adult Day Health providers cannot bill the transportation procedure code. Transportation is a separate and distinct procedure code and that service is not contracted to be provided by Adult Day Care providers thus preventing duplicate billing.</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:19:svapdxC1_1a_prnt:svcDelMthPtcDir" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:svcDelMthPtcDir" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:lbl_svcDelMthPtcDir" for="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:svcDelMthPtcDir" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:19: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:19:svapdxC1_1a_prnt:svcDelMthPvdrMgd" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:svcDelMthPvdrMgd" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:lbl_svcDelMthPvdrMgd" for="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:svcDelMthPvdrMgd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:19: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:19:svapdxC1_1a_prnt:svcPvdLegResp" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:svcPvdLegResp" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:lbl_svcPvdLegResp" for="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:svcPvdLegResp" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:txt_lbl_svcPvdLegResp" class="outputText">Legally Responsible Person</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:svcPvdRel" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:svcPvdRel" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:lbl_svcPvdRel" for="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:svcPvdRel" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:txt_lbl_svcPvdRel" class="outputText">Relative</span></label> </div> <div class="checkboxGroup"> <input id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:svcPvdLegGrd" type="checkbox" name="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:svcPvdLegGrd" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:lbl_svcPvdLegGrd" for="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:svcPvdLegGrd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:txt_lbl_svcPvdLegGrd" class="outputText">Legal Guardian</span></label> </div> </div> </div> <div class="pph"> <label id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:lbl_dtProviderTypes" for="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypes" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:txt_lbl_dtProviderTypes" class="outputText">Provider Specifications:</span></label> </div> <table id="svapdxC1_1_prnt:dtServicesPrnt:19: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:19:svapdxC1_1a_prnt:dtProviderTypes:hdrProvCat" class="outputText">Provider Category</span></th><th scope="col" ><span id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypes:hdrProvTyp" class="outputText">Provider Type Title</span></th></tr> </thead><tbody > <tr ><td ><input id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypeID" type="text" name="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypeID" value="223141" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypes:0:providerTypName" class="outputText">Individual</span></td> <td ><span id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypes:0:pvdTypeName" class="outputText" style="width: 100%;">Individual Provider</span></td> </tr> <tr ><td ><input id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypes:1:providerTypeID" type="text" name="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypes:1:providerTypeID" value="223144" style="display: none;" disabled="disabled" readonly="readonly" /><span id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypes:1:providerTypName" class="outputText">Agency</span></td> <td ><span id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypes:1:pvdTypeName" class="outputText" style="width: 100%;">Commercial Transportation Providers</span></td> </tr> </tbody> </table> <table id="svapdxC1_1_prnt:dtServicesPrnt:19: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:19:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceTypelbl" class="outputText">Service Type: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:19: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:19:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceNamelbl" class="outputText">Service Name: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_serviceName" class="outputText">Transportation</span> </div> </div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdCat" for="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdCat" class="outputText">Provider Category:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdCat" name="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:0: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:19:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdTypeName" for="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:19: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:19:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdTypeName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" name="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdTypeName" class="inputTextarea" readonly="readonly">Individual Provider</textarea></span> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:19: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:19:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualLic" for="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualLic1" class="outputText">License </span><span id="svapdxC1_1_prnt:dtServicesPrnt:19: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:19:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualLic"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualLic" name="svapdxC1_1_prnt:dtServicesPrnt:19: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:19:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualCert" for="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualCert1" class="outputText">Certificate </span><span id="svapdxC1_1_prnt:dtServicesPrnt:19: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:19:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualCert"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualCert" name="svapdxC1_1_prnt:dtServicesPrnt:19: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:19:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdQualOthStd" for="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:txt_lbl_pvdQualOthStd1" class="outputText">Other Standard </span><span id="svapdxC1_1_prnt:dtServicesPrnt:19: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:19:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdQualOthStd"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" name="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdQualOthStd" class="inputTextarea" readonly="readonly">There are no enrollment requirements for private transportation. Private transportation is defined as transportation by a vehicle owned by a volunteer organization, or a private individual, provided the vehicle is not used for commercial carriage. The provider must possess a valid CT driver's license and provide evidence of automobile insurance.</textarea></span> </div> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:19: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:19:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdVrfEnt" for="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:19: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:19:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdVrfEnt"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfEnt" name="svapdxC1_1_prnt:dtServicesPrnt:19: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:19:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:lbl_pvdVrfFreq" for="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:19: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:19:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:panel_pvdVrfFreq"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" name="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:0:svapdxC1_1b_prnt:pvdVrfFreq" class="inputTextarea" readonly="readonly">At the time of enrollment 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> <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:19:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_serviceTypelbl" class="outputText">Service Type: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_serviceType" class="outputText">Other Service</span> </div> <div class="firstIndent"> <span id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_serviceNamelbl" class="outputText">Service Name: </span><span id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_serviceName" class="outputText">Transportation</span> </div> </div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdCat" for="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdCat" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_lbl_pvdCat" class="outputText">Provider Category:</span></label> </div> <select id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdCat" name="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:1: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:19:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdTypeName" for="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdTypeName" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:19: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:19:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:panel_pvdTypeName"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdTypeName" name="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdTypeName" class="inputTextarea" readonly="readonly">Commercial Transportation Providers</textarea></span> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:19: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:19:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdQualLic" for="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualLic" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_lbl_pvdQualLic1" class="outputText">License </span><span id="svapdxC1_1_prnt:dtServicesPrnt:19: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:19:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:panel_pvdQualLic"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualLic" name="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualLic" class="inputTextarea" readonly="readonly">In order to receive payment from the Connecticut Home Care Program, all commercial transportation providers shall be regulated carriers and meet all applicable state and federal permit and licensure requirements, and vehicle registration requirements. Commercial transportation providers shall also meet all applicable Medicaid program enrollment requirements.</textarea></span> </div> </div> <div> <div> <label id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdQualCert" for="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualCert" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_lbl_pvdQualCert1" class="outputText">Certificate </span><span id="svapdxC1_1_prnt:dtServicesPrnt:19: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:19:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:panel_pvdQualCert"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualCert" name="svapdxC1_1_prnt:dtServicesPrnt:19: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:19:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdQualOthStd" for="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualOthStd" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:txt_lbl_pvdQualOthStd1" class="outputText">Other Standard </span><span id="svapdxC1_1_prnt:dtServicesPrnt:19: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:19:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:panel_pvdQualOthStd"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualOthStd" name="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdQualOthStd" class="inputTextarea" readonly="readonly"></textarea></span> </div> </div> </div> <div class="pph"> <span id="svapdxC1_1_prnt:dtServicesPrnt:19: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:19:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdVrfEnt" for="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdVrfEnt" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:19: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:19:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:panel_pvdVrfEnt"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdVrfEnt" name="svapdxC1_1_prnt:dtServicesPrnt:19: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:19:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:lbl_pvdVrfFreq" for="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdVrfFreq" class="outputLabel"> <span id="svapdxC1_1_prnt:dtServicesPrnt:19: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:19:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:panel_pvdVrfFreq"><textarea id="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdVrfFreq" name="svapdxC1_1_prnt:dtServicesPrnt:19:svapdxC1_1a_prnt:dtProviderTypesDetail:1:svapdxC1_1b_prnt:pvdVrfFreq" class="inputTextarea" readonly="readonly">At the time of enrollment and bi-annually 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">DSS requires any persons employed as an Independent Support Broker for this waiver submit to a State of Connecticut criminal background check. The fiscal intermediary is required to submit a report to the Department annually that includes the number of criminal background checks completed and the number of failed results. DSS has the discretion to refuse payments for individuals performing services who have been convicted of a felony, as defined in section 53a-25 of the Connecticut General Statutes, involving forgery under section 53a-137 of the Connecticut General Statutes; robbery under section 53a-133 of the Connecticut General Statutes; larceny under sections 53a-119,53a-122,53a-123, 53a124 of the Connecticut General Statutes; or of a violation of section 53a-290 to 53a-296, inclusive of the Connecticut General Statutes; involving vendor fraud, section 53-20 of the Connecticut General Statutes involving cruelty to persons; sections 53a-70, 53a-70a, 53a-70b, 53a-71, 53a-72b, or 53a-73a of the Connecticut General Statutes involving sexual assault: section 53a-59 of the Connecticut General Statutes involving assault; section 53a-59a of the Connecticut General Statutes involving assault of an elderly, blind, disabled, pregnant or mentally retarded person, and sections 53a-320 to 53a-323, inclusive of the Connecticut General Statutes involving abuse of elderly, blind disabled or mentally retarded persons. This review is carried out by the fiscal intermediary which the contract requires as part of consideration for employment by any Waiver participant.</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 Independent Support Broker to be a family member. The care manager monitors the appropriateness and effectiveness of the services provided as part of their required monthly monitoring contract. 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, 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. The participant or their conservator must sign timesheets to confirm the dates and times services were performed. The fiscal intermediary reviews timesheets for accuracy and whether they match the allocation in the service plan. Any discrepancy results in the notification to DSS prior to the issuance of payment. 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.).</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 fiscal intermediary is responsible to recruit, train, and assist with the enrollment process of qualified providers. The MMIS contractor also facilitates the enrollment process for providers using a web based enrollment program. The fiscal intermediary is mandated in their contract with the Department to establish working relationships with community providers and provide education to potential providers about the program services. All willing providers are sent an initial enrollment packet when requested. When inquiries from potential providers come directly to the Department, they are referred to the fiscal intermediary who will initiate the enrollment process. Additionally, the state's MMIS provider, HP Enterprises maintains a web site that provides extensive information to prospective providers. The website is ctdssmap.com. The application and instructions can be downloaded from the website. The provider is given a specific list of accompanying required documentation with their provider enrollment application. Provider relations and enrollment specialists within HP attempt to make the process as efficient as possible and provide providers with assistance during the enrollment process. The usual timeframe for enrollment is approximately 60 days but may be extended if the provider requests additional time to collect the required information.</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">Number and percent of Dept clinical staff licensure that is verified initially and annually. Numerator=total number of staff licenses verified Denominator=number of staff</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">Department of Public Health Records for Registered Nurses and Social Workers</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" checked="checked" 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" 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" 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" disabled="disabled" readonly="readonly"></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" checked="checked" 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" 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" 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" disabled="disabled" readonly="readonly"></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" checked="checked" 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" readonly="readonly">Initially and annually thereafter</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:dtPMPrntQPa:1:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:pmName" class="inputTextPct">Number and percent of Adult Day Centers that are certified through peer review by the CT Adult Day Care Association. Numerator=number of ADC centers certified Denominator= number of centers</span> </div> </div> <table id="svapdxCQ_1:dtPMPrntQPa: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:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Reports to State Medicaid Agency on delegated Administrative functions</span><div id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct">ADC certification listing is provided to the department quarterly by the Day Care Association updating the certification status</span></div></div></div><table id="svapdxCQ_1:dtPMPrntQPa: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:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsRpSma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsSaPct" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa: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:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxCQ_1:dtPMPrntQPa: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:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="inputTextarea" readonly="readonly">CT Adult Day Care Association</textarea></span></div></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxCQ_1:dtPMPrntQPa: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:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsFdCo" checked="checked" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsSaOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxCQ_1:dtPMPrntQPa: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:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPa: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:dtPMPrntQPa: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:dtPMPrntQPa:1:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxCQ_1:dtPMPrntQPa: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:dtPMPrntQPa:1:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:pmDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:pmDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:pmDaFdQu" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:pmDaRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:pmDaRpOthDsc" name="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:pmDaRpOthDsc" class="inputTextarea" readonly="readonly">CT Adult Day Care Association</textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:pmDaFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa: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:dtPMPrntQPa:1:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:pmDaFdCo" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa: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:dtPMPrntQPa:1:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:pmDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxCQ_1:dtPMPrntQPa:1:svQmPerfMeas:pmDaFdOtDsc" name="svapdxCQ_1:dtPMPrntQPa: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.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 independent support broker individual providers for whom criminal backgroung checks are conducted prior to providing personal care assistance services to waiver participants. Numerator= number of support broker provider with background checks prior to employment denominator = number of providers</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">Report from fiscal intermediary</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" 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">contracted fiduciary agency</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" 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" 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" disabled="disabled" readonly="readonly"></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" checked="checked" 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" 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 waiver providers, by provider type, that continue to meet waiver provider qualifications. numerator= total number providers licensed denominator = number of providers</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" checked="checked" 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" 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">Access Agency, HP Enterprises</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" checked="checked" 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" 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">HP enterprises and Access Agency</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" checked="checked" 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> <tr ><td > <div style="padding-bottom: 1.5em; width:90%;" > <span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:pmName" class="inputTextPct">Number and percent of non licensed/non certified provider applicants, by provider type who meet initial waiver qualifications. numerator=number of providers who meet qualifications denominator= total number of providers</span> </div> </div> <table id="svapdxCQ_1:dtPMPrntQPb: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="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Reports to State Medicaid Agency on delegated Administrative functions</span><div id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct"></span></div></div></div><table id="svapdxCQ_1:dtPMPrntQPb: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="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsSaPct" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:2: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:2:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxCQ_1:dtPMPrntQPb: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="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="inputTextarea" readonly="readonly">Access Agency and HP enterprises</textarea></span></div></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxCQ_1:dtPMPrntQPb: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="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsFdCo" checked="checked" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsSaOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxCQ_1:dtPMPrntQPb: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="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxCQ_1:dtPMPrntQPb: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="svapdxCQ_1:dtPMPrntQPb: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="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxCQ_1:dtPMPrntQPb: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="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:pmDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:pmDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:pmDaFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:pmDaRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:pmDaRpOthDsc" name="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:pmDaRpOthDsc" class="inputTextarea" readonly="readonly">HP enterprises and Access Agency</textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:pmDaFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb: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="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:pmDaFdCo" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb: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="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:pmDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxCQ_1:dtPMPrntQPb:2:svQmPerfMeas:pmDaFdOtDsc" name="svapdxCQ_1:dtPMPrntQPb: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.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">Number and percent of waiver service providers who receive training that they request of HP Services(formerly Electronic Data Systems) the state's MMIS contractor as specified in their contract with the state. Numerator = number who receive requested training. denominator=number who request training</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">Reports to State Medicaid Agency on delegated Administrative functions</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" checked="checked" 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" 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">contracted entity</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" checked="checked" 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" checked="checked" 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" 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">contracted entity</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" checked="checked" 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 Department cross matches providers with the HHS-OIG Fraud Protection and Detection Exclusion list to block participation of providers found on this list. Access Agencies perform checks of staff licensure routinely at time of annual performance review. The Access Agencies are required to have procedures in place to verify that subcontractors meet all of the criteria to be a waiver provider. They must provide documentation that the subcontractor meets Department standards and requirements to assure provider eligibility, adherence to program requirements and standards, quality of service delivery and that services are delivered in accordance with participants' plans of care.</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">Performing provider agencies have a grievance procedure that they may follow in the event they believe they have not been treated appropriately by the Access Agency. In circumstances such as these, the provider may contact the manager of the HCBS Unit who will review the situation and make appropriate interventions. The Fiscal Intermediary is contractually obligated to assist providers in meeting the provider qualifications needed to be a participating provider. They offer training programs both for existing providers as well as for providers who wish to enroll. Documentation of the grievances and all of the accompanying correspondance is maintained in a central file in the HCBS Unit.</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" checked="checked" 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" 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" checked="checked" 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">This section has been approved by CMS in the waiver amendment CT 0140.R05.03 that was approved in February of 2015. The state has assessed both residential and non-residential settings for compliance with the CMC final rules. The state has determined that all of the services in this waiver fully comport with the HCBS settings requirements including Adult Day Health, Adult Family Living and Assisted Living. The state engaged in a comprehensive evaluation process and has planned remediation and ongoing monitoring activities. The information below provides the description of the processes the state engaged in to reach this conclusion and also outlines some steps that state plans on taking to ensure compliance ongoing. The state provides services to residents of Residential Care Homes (RCH), a setting licensed by the Department of Public Health. There is a great deal of variation in the settings across the state. Our initial review suggests that some of the RCHs fully comport with the settings requirement while others need to make changes in order to come into compliance. Our assessment will also tell us if we have settings that are non-compliant. In those cases, DSS staff will visit each location and do further assessment and discuss remediation efforts before taking any further actions that will impact waiver participants. Ultimately the participant may need to choose between receiving waiver services, moving or remaining in their current setting without waiver services. To begin its assessment of Residential Care Homes (RCHs), DSS identified the number of participants residing in RCHs. Our analysis identified 254 participants residing in RCHs. RCHs vary widely in their appearance, size and home like qualities. DSS recognizes that some RCHs are fully compliant with the HCB settings requirements while others will need to make changes to become compliant. To determine whether RCHs are in compliance with the HCB settings requirements, DSS took a number of steps. First, all care managers were trained on the final rule and were introduced to a survey to be utilized from September 1, 2014 through February 28, 2015 when performing the annual or semi-annual reassessment of participant&#8217;s residing in an RCH (assessments take place at the RCH). The survey asks participants questions about the RCH in the following five categories: choice of residence, community access and integration, living space (e.g., physical access, ability to control schedule, privacy, choice regarding meals, etc.), staff interactions and privacy, and services (the participant&#8217;s experience with services). Care managers will evaluate if the setting was clearly chosen by the participant as part of the person centered plan. DSS also developed and distributed a survey to all RCHs to do a self-assessment of compliance. This survey includes questions similar to the participant survey in the same five categories. In addition, DSS developed a brief survey for care managers to provide their perspective on RCH&#8217;s compliance with the HCB settings rule. Review of the findings from the various surveys will help DSS identify areas that changes will need to be made to bring RCHs into full compliance. All of the survey data will be analyzed and it is anticipated that some on site evaluations will need to be done by DSS staff. On November 19, 2014 DSS conducted a training for the RCH association to ensure understanding of the HCB settings requirements. DSS will also work with DPH, which licenses RCHs, to update regulatory documents to assure compliance with the HCB settings requirements. This will be accomplished by December 31, 2015. DSS will also add language to its program regulations to reflect the HCB settings requirements by December 31, 2015. One of the most challenging areas is the CMS expectation that the participant have access to food at any time. DPH and local public health departments have requirements that prohibit residents having ongoing access to the kitchens. As a result, each setting will need to determine different ways that this requirement can be met. Some initial ideas include the resident's ability to have a small refrigerator in their rooms. DSS will review the results of the RCH surveys to identify homes that might not be fully compliant with the HCB settings requirements. DSS anticipates that some RCHs are not fully compliant with the HCB settings requirements. Therefore, in addition to the general remediation and monitoring activities listed above, DSS will work with individual providers identified as potentially not compliant to address any non-compliance. DSS will inform individual RCHs of non-compliance items and request the RCH to submit a corrective action plan (CAP) that identifies the steps the RCH will take to remediate the identified issues and the timelines for each step and anticipated compliance. DSS will require the RCH to provide periodic updates on its progress. DSS is working with a stakeholder group that includes the United States Department of Housing and Urban Development (HUD) to assist housing providers, including RCHs, comply with the HCB settings requirements. One of the planned initiatives is to provide a competitive grant to RCHs that are affiliated with nursing facilities to help them comply with the HCB settings requirements. If an RCH is unable or unwilling to comply with the HCB settings requirements, DSS will notify the care manager(s) for the affected participant(s), and the care manager will help the participant select and then transition to a setting that meets the HCB settings requirements. DSS assures that it will provide reasonable notice and due process to any participant that needs to transition to another setting. DSS anticipates that the relocation process will take approximately six months. Through the person centered planning process the care manager will ensure that the participant is provided information about alternative settings that comply with HCB settings requirements and makes an informed choice of an alternative setting. The care manager will ensure that all services are in place in advance of a participant&#8217;s transition and will monitor the transition to ensure successful placement and continuity of services. This will include increased monitoring before and after transition, updating the participant&#8217;s service plan as needed, and tracking the success of the transition. While care managers will provide information on options and encourage participants to transition to a setting that complies with the HCB settings requirements, some participants may choose to remain in their current setting and disenroll from the waiver. If DSS determines that an RCH has the effect of isolating participants from the broader community but otherwise has the qualities of HCB settings, DSS will submit information to CMS for heightened scrutiny review. To ensure ongoing compliance, as part of the initial assessment of participants for enrollment in this waiver, care managers (who have been trained on the new rule) will evaluate the RCH&#8217;s compliance with the HCB settings requirements using a checklist that ensures the setting meets the HCB settings requirements, including: &#8226; The participant has a lease; &#8226; The participant has privacy including lockable doors; &#8226; The participant has a choice of roommates; &#8226; The participant has freedom to control his/her own schedule; &#8226; The participant is free to have visitors; and &#8226; The setting is integrated into the community and facilitates access to community activities such as movies, shopping, and recreational activities. Similar to the evaluation at initial assessment, if a participant chooses to move into an RCH, the care manager will use the checklist to ensure the setting meets the HCB settings requirements. Also, on an ongoing basis, as part of their home visits, care managers will evaluate the RCH&#8217;s compliance with the HCB settings requirements. This will ensure that all settings where individuals receive services will continue to meet the HCB settings requirements on an ongoing basis. If at any time (during initial assessment, when a participant moves to a RCH, or during a home visit) the care manager determines that an RCH is not compliant with the HCB settings requirements, the care manager will discuss this with the participant and offer the participant alternative settings that are compliant. If the applicant/participant chooses to reside in the non-compliant setting, he/she would not be eligible for the HCBS program. Adult Family Living- This service is provided in the home of the participant or of the caregiver. This service comports with CMS requirements as: - it is selected as a service by the individual from a range of available services and qualified providers. - the participant understands that selecting this service setting also means they are selecting this service provider as part of a bundled rate -additional home and community based services are selected by the participant from a range of qualified service providers to address a need identified in the person centered planning process The setting is chosen by the waiver participant as part of the person centered planning process. The rate for the service is a bundled rate but 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 case managers complete person centered assessments for new waiver participants, they will be responsible to assess the setting's compliance with the required settings characteristics. The provider for this service is agency based therefore the provider does not own or control the home in which the waiver participant resides. Assisted Living- this service fully comports with CMS requirements as: -the setting is integrated in and supports and facilitates access to the greater community - facilitate interaction with non-Medicaid participants -has lockable doors facilitating privacy - each participant has a lease -if the participate chooses to share a unit, they have freedom to choose their roommate -the participants have control over their own schedule and are free to decorate their unit as they choose -the unit has kitchen facilities in each allowing access to food at any time -visitors are permitted at any time -the setting is physically accessible - the setting is chosen by the participant as part of the person centered planning process and participants are aware that choosing this setting provides a specified service provider that provides a bundled services - additional services may be selected by the participant from a list of qualified service providers. Based on several assessment activities, DSS has concluded that Assisted Living providers are in compliance with the new HCB settings requirements. DSS reviewed the Department of Public Health (DPH) regulation for Assisted Living Services and determined that the HCB settings requirements are specified in the DPH regulations, so DSS determined that the regulations comply with the new HCB settings requirements, and no changes need to be made to the regulations. This also indicates that the providers are aware of and in compliance with the HCB settings requirements. The regulations for assisted living are very clear that persons reside in individual units, with cooking facilities, and have the protection of a lease agreement. In addition to reviewing the regulations, DSS met with representatives of the Connecticut Assisted Living Association and confirmed that all communities are required to have leases with their tenants. As part of DSS&#8217; ongoing quality assurance efforts, DSS staff complete audits of assisted living providers. Each year, DSS audits two to three different communities. The audit process includes interviews with HCBS participants. DSS staff have directly observed that settings are compliant with HCB setting requirements. Participants have privacy in their units, have access to food at any time, and can have visitors at any time, and the setting is physically accessible. Although DSS has concluded that Assisted Living is fully compliant with the HCB settings requirements, DSS will implement remediation and monitoring activities to ensure ongoing compliance. The state has assessed this service and the CMS final rules requirements are specified in the Department of Public Health regulations. To complete this assessment process, the state met with representatives of the Assisted Living provider Association and confirmed that all communities are required to have leases with their tenants. We also will review our own regulations and ensure that language is included in the regulations that specifies the requirements included in the final rule. This will be completed by 12/31/15. Although DSS has concluded that Assisted Living complies with the HCB settings requirements, DSS will strengthen the language in its program regulations to specifically reflect the HCB settings requirements. In addition, DSS has incorporated review for compliance with HCB settings requirements in its regular quality assurance audits of assisted living providers. Each year DSS audits two to three different communities. Our visits will include an evaluation of compliance with the HCBS settings requirements. The audit includes interviews with HCBS participants. Adult Day Health: this service comports with CMS requirements as it is: - chosen by the participant from a selection of services from qualified providers - it is selected by the participant as part of the person centered planning process - it facilitates integration to community activities - it facilitates interaction with non-Medicaid recipients - the certification process emphasizes participants' rights to privacy, dignity and respect. The state has assessed the Adult Day Health Service with regard to the new settings requirements. Initially, the state met with the Adult Day Care Association certification team to discuss the certification process. It was determined that the process, although it does look at the home-like setting, could have stronger language that comports with the CMS final rules specifications. By 06/30/15, the state will work with the association to include language in the certification standards that includes language from the final rules. In addition, in collaboration with the ADC Association, the Department specifically reviewed weekly and monthly calendars for programs that were adjacent to or on the grounds of a non-public facility. There are several programs located adjacent to a facility and others that are on the grounds of communities that have a range of levels of care ranging from complete independent living to nursing home. In all cases, the activities calendars indicated that the program serves to facilitate integration into the community and interaction with non-HCBS program participants. For example, one Adult Day Health provider had activities such as a trip to the Hartford Symphony, games, outdoor gardening, movies, religious services, bocce, an outing to a restaurant for lunch, shopping, reiki, manicures, a picnic at a local park as well as other club type activities. DSS staff have also visited a number of Adult Day Health providers and overall were quite impressed by the quality and range of programming and services offered. To further review compliance of Adult Day Health providers located adjacent to or on the grounds of a private nursing facility, DSS developed and distributed a brief survey for care managers to complete to provide their perspective on the compliance of these Adult Day Health providers with the HCB settings requirements. Care managers were asked to assess nine statements that reflected the HCB settings requirements. For example, &#8220;Participants socialize with their peer, including non-HCBS participants, and engage in various interactive activities.&#8221; The care managers were given a choice of five response options for each statement: Completely False; Partially False; Neither True nor False; Partially True; and Completely True. Each response option was assigned a score from 1 to 5 as follows: 1-Completely False; 2-Partially False, 3-Neither True nor False, 4-Partially True; and 5-Completely True. Overall, care managers reported that these Adult Day Health centers comply with the HCB settings requirements reflected in the survey. Responses from all centers averaged an aggregate score of four or higher for each statement in the survey. The lowest aggregate response score was 4.19 for the statement &#8220;The center supports participant access to the surrounding community (not on the grounds of the nursing facility), e.g., through walking groups and/or field trips.&#8221; One center received an average score of three for that statement, and another center received an average score of two. DSS will follow up with these two centers. No other center received a score below a four on any of the statements. Some of the providers are located on the grounds of a community that offers a range of services from independent living to skilled nursing. A couple of others are located adjacent to nursing homes so that health services such as physical or occupational therapy can be provided to the participant. As a service that addresses health care needs, this is an appropriate setting and in no way impacts or limits access into the community but instead makes additional services available to the waiver participant. Based on DSS&#8217; review of the service definition and certification standards, direct observation, review of weekly and monthly schedules of activities, and analysis of survey data supplied by care managers, DSS has concluded that Adult Day Health fully comports with the HCB settings requirements. While DSS has determined that Adult Day Health complies with the HCB settings requirements, DSS will follow up with the two centers that received a score below a four on a statement on the Adult Day Health survey described above and work with them on a quality improvement plan. Also, DSS will work with the certification committee of the ADC association to include, by June 30, 2015, language in their certification standards to more clearly reflect the HCB settings requirements. DSS will also revise its own program regulations to reflect the HCB settings requirements. This will be accomplished by December 31, 2015. In order to ensure ongoing compliance, visits to Adult Day Health providers will be integrated into DSS&#8217; ongoing quality assurance activities.</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">Total Plan of Care</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" checked="checked" 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" checked="checked" 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">Clients who choose not to have care management services are determined to be "self directed." For these clients, Department staff may perform the annual reevaluation and level of care determination and authorize the service plan. Staff who perform these functions are either Registered Nurses licensed to practice nursing in the State of CT or Social Workers who meet the same qualifications as the Care Managers as specified in Appendix C-1/C-3</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">At the point of intake, applicants to the waiver program are asked to identify a "responsible party" or other person they would like to have present for the assessment visit. When the care manager calls to make the appointment, he/she generally calls the person identified on the referral as wanting to be present for the assessment visit. The visit is scheduled at a time convenient for both the client and the person or persons they wish to be included in the visit. The care manager discusses with the potential participant their choices between home care and institutional services. The care manager is expected to fully inform the applicant about services available and different agencies. The client is provided a W-990, The CT Home Care Program for Elders, Your Rights and Responsibilities. This document outlines choice of services, providers, the participant's right to participate in and have control over their services, their rights will be respected by service providers and they should expect high quality in the care or services they receive. The client is asked to sign an Informed Consent Form (W-889)that explains their choices in detail and are given a copy of the document as well as other documents they sign. Participants are required to sign a copy of their Total Plan of Care indicating their agreement with the 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">(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">Once the referral is processed by HCBS Unit staff and the client appears to meet functional and financial eligibility criteria for the waiver, the referral is sent to an Access Agency for the initial evaluation. The Care Manager meets with the client and his or her representative and explains the program prior to initiating the assessment. If the client consents, the care manager initiates the assessment. The uniform assessment instrument evaluates multiple domains including health, function, psychosocial, environment, cognition, support system and finances. Risk indicators are discussed with the client and/or their representative. The department is currently in the process of transitioning to a Uniform Assessment Instrument that will be used across all waivers as well as the Community First Choice state plan option. Based on the assessment, needs are identified and service options are discussed with the participant and their representative. Options regarding service providers are presented for the client to choose their services and providers. The assessment is utilized to develop client-centered goals and plans are developed that assist the client in achieving those goals. The Department, as part of its audit process, reviews records to ensure that client goals are identified and reviewed at least annually. Once the plan is developed, the costs of the plan are calculated. The client and/or their representative is asked to sign off on the plan indicating their approval and/or agreement with it. The final plan of care is submitted to the department for utilization review and to ensure that needs and goals are addressed by the plan. The Access Agencies are required by their contract with the department to perform monthly monitoring contacts with the clients and/or their representatives to evaluate the plan and if there are any changes that would necessitate a change in the plan. The contract further requires that the Care Manager change the plan to reflect changes in client needs. This occurs on a continuous basis. Regulations of CT State Agencies 17b-342(d)(7) state: For the Connecticut Home Care Program, all home care services shall be included as part of a written plan of care developed initially and updated regularly by the access agency, the assisted living service agency, department staff or department designee. The plan of care shall specify the start date of services, services, type, frequency, cost, funding source and the providers of all home care services. The type and frequency of services contained in the plan of care shall be based upon the documented needs found in the assessment of the elderly person’s needs and shall be reimbursed by the department only when it is determined that each service is needed in order to avoid institutional placement. For any services where the client would be at risk if the schedule of the service varied, a back-up plan shall be identified in the total plan of care. Services not included as part of the approved plan of care or not covered by sections 17b-342-1 to 17b-342-5, inclusive, of the Regulations of Connecticut State Agencies are not eligible for reimbursement from the Connecticut Home Care Program. The client'’s individualized plan of care must be signed by the client or the client'’s representative. The Total Plan of Care is coordinated by the care manager and includes not only waiver and state plan services but also in-kind, Medicare covered, other insurance covered services and other federal funded such as Older American's Act programs.</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 choose their services and 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 participant and his/her representative, and any other person identified by the participant collaborate to assess the individual from a multidimentional perspective as well as any risk factors including: inadequate supervision, social isolation, cognitive impairment, fall risk, inability to summon assistance, emotional and behavioral issues, and communication capabilities. This information is used to provide the background necessary to identify areas of potential risk to the waiver participant. When risk issues are identified, the Care Manager discusses these issues with their Supervisor and/or interdisciplinary team and then provides feedback to the waiver participant regarding the area(s) of concern. This allows the participant 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 participant and/or their representative. A back-up plan is informal, utilizing in-kind support from family, friends, or neighbors, and formal, provided by the service agency which prioritizes clients whose health and safety would be at risk without scheduled service providers. All clients are reviewed for the need for a back up plan. The back up plan is indicated on the Total Plan of Care. The waiver participant has the right to accept, reject or modify recommendations that address risk. 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. If this is not possible, then the waiver participant is issued a Notice of Action (NOA), indicating discontinuance from the waiver. The participant 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">During the development of the Total Plan of Care, participants will select providers from a list of credentialed providers prepared by the Department's fiscal intermediary. The Fiscal Intermediary maintains the list of credentialed waiver providers that includes services provided, rates and area covered. The care managers make a concerted effort to provide the clients with as many choices as possible and the expectation is that there is documentation in the clinical record of the choices given. The client may request a copy of the list at any time. If the client does not have a specific choice, providers are assigned on a rotating basis as long as the provider can meet all of the specifications requested by the client such as language spoken and the days and times that services are available. The Care Manager will describe the services available from providers on the list. Participants choose providers from the list and their signature on the total Plan of Care acknowledges freedom of choice. Additionally, in every monthly monitoring contact the client is asked if they are satisfied with the services provided and if there are any problems with the delivery of the formal services. If the client indicates there are problems, then changing to another service provider is discussed as an option and the Care Manager again reviews with the participant the service providers available to choose from. Again, that documentation is found in the clinical record. New providers are added to the list as they meet the qualifications and are enrolled. Once added to the list, the care managers provide the info to the participant as part of the monthly monitoring contact if the client wishes to change providers and is also provided as a choice to all new clients.</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">HCBS unit staff review 100% of all new service plans and must authorize them in order to initiate service. Utilization Review Nurses match needs with services to ensure all health and safety needs are being met. HCBS unit staff conducts annual client record reviews for each of the three Access Agencies. Approximately one hundred (150) client records are randomly selected for review. The reviews include an examination of the client'’s most recent reassessment and confirm that the identified critical needs are consistent with the POC. The POC is reviewed to ensure that all identified needs are being met. HCBS unit staff conducts client satisfaction surveys in each of the five areas of the state that define the Access Agencies service areas. ACU client record reviews are conducted to monitor contractual agreements. The Access Agencies are contractually obligated to conduct client record reviews including assessing appropriateness of POC and report annually to the Department of Social Services. Access Agencies must update the POC at the time of reassessment or when a significant change occurs in the client'’s status, and utilize care plans consistent with the program’'s Uniform Client Care Plan. The Uniform Client Care Plan identifies provider, type of service, number of hours provided, date service began, and date service was discontinued, noting the need for a back up plan. These services are monitored by the Department of Social Services through Quality Assurance and Client Satisfaction Annual Reports generated by the Access Agencies. On annual reassessment, ACU staff select for review, every 10th care plan submitted monthly. The review consists of an evaluation of whether the plan is meeting health and safety needs of the participant and monitors outlier care plans(utilization below 20% or above 80% of the cost limits).</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" 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" checked="checked" 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" 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">The Access Agency Care Managers are responsible for monitoring the implementation of the service plan and participant health and welfare. By contract, the Access Agency conducts monthly contacts with the client, the client's representative or provider by telephone or home visit. Monthly contacts verify that services in the plan of care meet current needs of the client, verify that services are being provided as specified in the plan of care, verify that the plan remains within cost limits, verify satisfaction with services, verify that client goals remain appropriate and revise goals as needed, identify any potential problems relating to participant's health, safety or participation in the waiver and implement corrective actions as needed, verify that the corrective action is effective and verify that the informal support system remains active and provides the assistance noted on the Total Plan of Care. The monthly monitoring contact has specific questions that must be answered by the participant or their representative. The questions include, are you satisfied with your services? Is there a change in your level of satisfaction with the services provided? Any problems with formal services? Any problems with informal services or assistance? The Total Plan of Care is reviewed which includes whether a back-up is needed in the event a specific service is not delivered. The back up plan is documented on the Total Plan of Care which is reviewed as part of the monitoring contact. The Total Plan of Care includes both waiver services and non-waiver services and both types of services are included in this monitoring contact. The care managers are required to conduct face-to-face visits with the clients as often as needed but no less frequently than 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">Number and percent of service plans that address client risk factors Numerator=total number of service plans that address needs denominator=total number of service plans</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">Record reviews, on-site</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">Record reviews may also be off-site, desk reviews</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" 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" 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: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">contracted Access Agency</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" checked="checked" 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" checked="checked" 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" readonly="readonly">non-representative sample</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" 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" disabled="disabled" readonly="readonly"></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> <tr ><td ><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsTypeLbl" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsType"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsTypeDDDiv"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsType" class="inputText">Record reviews, on-site</span><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsOtherNamelblDiv"><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsNameLbl" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsName"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:panel_dsName"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsName" class="inputTextPct"></span></div></div></div><table id="svapdxDQ_1:dtPMPrnt_spa: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_spa:0:svQmPerfMeas:dtDataSource:1:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsrp1"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:PMrp1div" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsRpSma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsRpSma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:lbl_dsRpSma" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsRpSma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsfom1"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsFdWkdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsFdWk" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:lbl_dsFdWk" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsFdWk" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dssa1"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsSaPctdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsSaPct" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsSaPct" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:lbl_dsSaPct" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsSaPct" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa: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_spa:0:svQmPerfMeas:dtDataSource:1:dsrp2"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsRpOpadiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsRpOpa" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:lbl_dsRpOpa" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsRpOpa" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsfom2"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsFdModiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsFdMo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:lbl_dsFdMo" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsFdMo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dssa2"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsSaLtPct" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsSaLtPct" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:lbl_dsSaLtPct" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsSaLtPct" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa: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_spa:0:svQmPerfMeas:dtDataSource:1:dsrp3"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsRpCmadiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsRpCma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:lbl_dsRpCma" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsRpCma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsfom3"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsFdQudiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsFdQu" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsFdQu" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:lbl_dsFdQu" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsFdQu" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dssa3" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsSaRsdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsSaRs" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:lbl_dsSaRs" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsSaRs" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:lbl2_dsSaRsDsc" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsSaRsDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:panel_dsSaRsDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsSaRsDsc" name="svapdxDQ_1:dtPMPrnt_spa: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_spa:0:svQmPerfMeas:dtDataSource:1:dsrp4"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsRpOthdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsRpOth" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:lbl_dsRpOth" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsRpOth" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:lbl2_dsRpOthDsc" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsRpOthDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:panel_dsRpOthDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsRpOthDsc" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsRpOthDsc" class="inputTextarea" readonly="readonly">Contracted Access Agency</textarea></span></div></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsfom4"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsFdAndiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsFdAn" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:lbl_dsFdAn" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsFdAn" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dssa4" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsSaStrdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsSaStr" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:lbl_dsSaStr" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsSaStr" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:lbl2_dsSaStrDsc" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsSaStrDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:panel_dsSaStrDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsSaStrDsc" name="svapdxDQ_1:dtPMPrnt_spa: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_spa:0:svQmPerfMeas:dtDataSource:1:dsrp5"></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsfom5"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsFdCodiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsFdCo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsFdCo" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:lbl_dsFdCo" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsFdCo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dssa5" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsSaOthdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsSaOth" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsSaOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:lbl_dsSaOth" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsSaOth" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:lbl2_dsSaOthDsc" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsSaOthDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:panel_dsSaOthDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsSaOthDsc" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsSaOthDsc" class="inputTextarea" readonly="readonly">Supervisory review of a minimum of 5% of the records quarterly</textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsrp6"></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsfom6"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsFdOtdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsFdOt" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:lbl_dsFdOt" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsFdOt" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:lbl2_dsFdOtDsc" for="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsFdOtDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:panel_dsFdOtDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spa:0:svQmPerfMeas:dtDataSource:1:dsFdOtDsc" name="svapdxDQ_1:dtPMPrnt_spa: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_spa: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_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" checked="checked" 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" checked="checked" 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" readonly="readonly">contracted Access Agency</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">every 18 months</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_spa:1:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:pmName" class="inputTextPct">Number and percent of service plans that appropriately identify the need for back up plans. numerator=number of plans with backup plans denominator= total number of plans</span> </div> </div> <table id="svapdxDQ_1:dtPMPrnt_spa: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_spa:1:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Record reviews, on-site</span><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct">In addition, off site record reviews are also conducted</span></div></div></div><table id="svapdxDQ_1:dtPMPrnt_spa: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_spa:1:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsSaPct" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa: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_spa:1:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa: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_spa:1:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxDQ_1:dtPMPrnt_spa: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="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="inputTextarea" readonly="readonly">Contracted Access Agency</textarea></span></div></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxDQ_1:dtPMPrnt_spa: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_spa:1:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsFdCo" checked="checked" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsSaOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="inputTextarea" readonly="readonly">non-representative sample</textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxDQ_1:dtPMPrnt_spa: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_spa:1:svQmPerfMeas:dtDataSource:0:dssa6"></span></td> </tr> </tbody> </table> </td> </tr> <tr ><td ><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsTypeLbl" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsType"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsTypeDDDiv"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsType" class="inputText">Record reviews, on-site</span><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsOtherNamelblDiv"><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsNameLbl" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsName"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:panel_dsName"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsName" class="inputTextPct"></span></div></div></div><table id="svapdxDQ_1:dtPMPrnt_spa:1: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_spa:1:svQmPerfMeas:dtDataSource:1:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsrp1"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:PMrp1div" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsRpSma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsRpSma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:lbl_dsRpSma" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsRpSma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsfom1"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsFdWkdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsFdWk" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:lbl_dsFdWk" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsFdWk" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dssa1"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsSaPctdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsSaPct" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsSaPct" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:lbl_dsSaPct" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsSaPct" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsrp2"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsRpOpadiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsRpOpa" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:lbl_dsRpOpa" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsRpOpa" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsfom2"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsFdModiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsFdMo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:lbl_dsFdMo" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsFdMo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dssa2"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsSaLtPct" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsSaLtPct" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:lbl_dsSaLtPct" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsSaLtPct" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1: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_spa:1:svQmPerfMeas:dtDataSource:1:dsrp3"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsRpCmadiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsRpCma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:lbl_dsRpCma" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsRpCma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsfom3"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsFdQudiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsFdQu" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:lbl_dsFdQu" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsFdQu" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dssa3" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsSaRsdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsSaRs" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:lbl_dsSaRs" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsSaRs" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:lbl2_dsSaRsDsc" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsSaRsDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:panel_dsSaRsDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsSaRsDsc" name="svapdxDQ_1:dtPMPrnt_spa:1: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_spa:1:svQmPerfMeas:dtDataSource:1:dsrp4"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsRpOthdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsRpOth" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:lbl_dsRpOth" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsRpOth" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:lbl2_dsRpOthDsc" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsRpOthDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:panel_dsRpOthDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsRpOthDsc" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsRpOthDsc" class="inputTextarea" readonly="readonly">contracted entity</textarea></span></div></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsfom4"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsFdAndiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsFdAn" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsFdAn" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:lbl_dsFdAn" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsFdAn" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dssa4" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsSaStrdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsSaStr" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:lbl_dsSaStr" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsSaStr" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:lbl2_dsSaStrDsc" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsSaStrDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:panel_dsSaStrDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsSaStrDsc" name="svapdxDQ_1:dtPMPrnt_spa:1: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_spa:1:svQmPerfMeas:dtDataSource:1:dsrp5"></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsfom5"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsFdCodiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsFdCo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsFdCo" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:lbl_dsFdCo" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsFdCo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dssa5" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsSaOthdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsSaOth" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsSaOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:lbl_dsSaOth" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsSaOth" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:lbl2_dsSaOthDsc" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsSaOthDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:panel_dsSaOthDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsSaOthDsc" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsSaOthDsc" class="inputTextarea" readonly="readonly">supervisory review of a minimum of 5% record review</textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsrp6"></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsfom6"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsFdOtdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsFdOt" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:lbl_dsFdOt" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsFdOt" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:lbl2_dsFdOtDsc" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsFdOtDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:panel_dsFdOtDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsFdOtDsc" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:dtDataSource:1:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:1: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_spa: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_spa:1:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxDQ_1:dtPMPrnt_spa: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_spa:1:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:pmDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:pmDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:pmDaFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:pmDaRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:pmDaRpOthDsc" name="svapdxDQ_1:dtPMPrnt_spa:1: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:1:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:pmDaFdAn" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa: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_spa:1:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:pmDaFdCo" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa: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_spa:1:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:pmDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spa:1:svQmPerfMeas:pmDaFdOtDsc" name="svapdxDQ_1:dtPMPrnt_spa: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="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:pmName" class="inputTextPct">Number and percent of service plans reviewed by HCBS staff that appear to meet identified needs at the time of the initial assessment. Numerator= plans that appear to meet needs denominator= total number of plans</span> </div> </div> <table id="svapdxDQ_1:dtPMPrnt_spa: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="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Record reviews, off-site</span><div id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct"></span></div></div></div><table id="svapdxDQ_1:dtPMPrnt_spa: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="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsRpSma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsSaPct" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:2: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:2:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:2: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:2:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxDQ_1:dtPMPrnt_spa: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="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="inputTextarea" readonly="readonly">Contracted access agencies</textarea></span></div></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxDQ_1:dtPMPrnt_spa: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="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsFdCo" checked="checked" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsSaOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxDQ_1:dtPMPrnt_spa: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="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spa: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="svapdxDQ_1:dtPMPrnt_spa: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="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxDQ_1:dtPMPrnt_spa: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="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:pmDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:pmDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:pmDaFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:pmDaRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:pmDaRpOthDsc" name="svapdxDQ_1:dtPMPrnt_spa:2: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:2:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:pmDaFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa: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="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:pmDaFdCo" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa: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="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:pmDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spa:2:svQmPerfMeas:pmDaFdOtDsc" name="svapdxDQ_1:dtPMPrnt_spa: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="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 client records reviewed that contain required client authorization and indication of choice forms. numerator=number of records that contain required documents denominator=number of records reviewed</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">Record reviews off site as well</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" 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" checked="checked" 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" checked="checked" 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" readonly="readonly">Contracted access agency</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" checked="checked" 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" readonly="readonly">non representative sample</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> </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" 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" checked="checked" 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" readonly="readonly">Every 18 months</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_spb:1:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:pmName" class="inputTextPct">Number and percent of service plans that are within cost caps specified in the waiver. numerator=number of plans within cost caps denominator=number of records reviewed</span> </div> </div> <table id="svapdxDQ_1:dtPMPrnt_spb: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_spb:1:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Record reviews, on-site</span><div id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct">off site record reviews are also conducted</span></div></div></div><table id="svapdxDQ_1:dtPMPrnt_spb: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_spb:1:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsRpSma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsSaPct" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb: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_spb:1:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb: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_spb:1:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxDQ_1:dtPMPrnt_spb: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="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="inputTextarea" readonly="readonly">Access Agency</textarea></span></div></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxDQ_1:dtPMPrnt_spb: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_spb:1:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsFdCo" checked="checked" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsSaOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="inputTextarea" readonly="readonly">100% review at initial assessment. Every 10th record at reassessment. a non-representative sample during on and off site record reviews</textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxDQ_1:dtPMPrnt_spb: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_spb: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_spb: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_spb:1:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxDQ_1:dtPMPrnt_spb: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_spb:1:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:pmDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:pmDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:pmDaFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:pmDaRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:pmDaRpOthDsc" name="svapdxDQ_1:dtPMPrnt_spb:1: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:1:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:pmDaFdAn" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb: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_spb:1:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:pmDaFdCo" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb: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_spb:1:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:pmDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spb:1:svQmPerfMeas:pmDaFdOtDsc" name="svapdxDQ_1:dtPMPrnt_spb: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="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 waiver participants reviewed whose service plans were revised, as needed to address changing needs. Numerator= number of plans appropriately revised denominator = total number of plans</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">Record reviews, on-site</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"></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" 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" 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" checked="checked" 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" checked="checked" 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" readonly="readonly">Access Agency</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" checked="checked" 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" checked="checked" 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" readonly="readonly">non representative sample</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" 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" checked="checked" 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">Number and percent of service plans that are updated and revised annually. numerator= number of service plans revised denominator = 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" 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" checked="checked" 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" 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" 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: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">contracted Access Agency</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" 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" checked="checked" 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" readonly="readonly">5% of the records per quarter</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> <tr ><td ><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsTypeLbl" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsType"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsTypeDDDiv"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsType" class="inputText">Analyzed collected data (including surveys, focus group, interviews, etc)</span><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsOtherNamelblDiv"><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsNameLbl" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsName"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:panel_dsName"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsName" class="inputTextPct"></span></div></div></div><table id="svapdxDQ_1:dtPMPrnt_spc:1: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_spc:1:svQmPerfMeas:dtDataSource:1:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsrp1"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:PMrp1div" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsRpSma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsRpSma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:lbl_dsRpSma" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsRpSma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsfom1"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsFdWkdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsFdWk" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:lbl_dsFdWk" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsFdWk" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dssa1"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsSaPctdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsSaPct" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsSaPct" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:lbl_dsSaPct" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsSaPct" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1: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:1:dsrp2"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsRpOpadiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsRpOpa" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:lbl_dsRpOpa" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsRpOpa" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsfom2"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsFdModiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsFdMo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:lbl_dsFdMo" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsFdMo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dssa2"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsSaLtPct" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsSaLtPct" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:lbl_dsSaLtPct" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsSaLtPct" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1: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_spc:1:svQmPerfMeas:dtDataSource:1:dsrp3"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsRpCmadiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsRpCma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:lbl_dsRpCma" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsRpCma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsfom3"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsFdQudiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsFdQu" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:lbl_dsFdQu" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsFdQu" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dssa3" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsSaRsdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsSaRs" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:lbl_dsSaRs" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsSaRs" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:lbl2_dsSaRsDsc" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsSaRsDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:panel_dsSaRsDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsSaRsDsc" name="svapdxDQ_1:dtPMPrnt_spc:1: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_spc:1:svQmPerfMeas:dtDataSource:1:dsrp4"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsRpOthdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsRpOth" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:lbl_dsRpOth" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsRpOth" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:lbl2_dsRpOthDsc" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsRpOthDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:panel_dsRpOthDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsRpOthDsc" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsRpOthDsc" class="inputTextarea" readonly="readonly">Contracted access agencies</textarea></span></div></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsfom4"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsFdAndiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsFdAn" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:lbl_dsFdAn" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsFdAn" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dssa4" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsSaStrdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsSaStr" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:lbl_dsSaStr" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsSaStr" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:lbl2_dsSaStrDsc" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsSaStrDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:panel_dsSaStrDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsSaStrDsc" name="svapdxDQ_1:dtPMPrnt_spc:1: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_spc:1:svQmPerfMeas:dtDataSource:1:dsrp5"></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsfom5"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsFdCodiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsFdCo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsFdCo" checked="checked" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:lbl_dsFdCo" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsFdCo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dssa5" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsSaOthdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsSaOth" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsSaOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:lbl_dsSaOth" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsSaOth" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:lbl2_dsSaOthDsc" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsSaOthDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:panel_dsSaOthDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsSaOthDsc" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsSaOthDsc" class="inputTextarea" readonly="readonly">every 10th record at annual reassessment and non-representative sample at the time of on or off site record reviews</textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsrp6"></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsfom6"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsFdOtdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsFdOt" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:lbl_dsFdOt" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsFdOt" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:lbl2_dsFdOtDsc" for="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsFdOtDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:panel_dsFdOtDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1:dsFdOtDsc" name="svapdxDQ_1:dtPMPrnt_spc:1:svQmPerfMeas:dtDataSource:1: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: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_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" checked="checked" 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">Contracted access agencies</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" 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" checked="checked" 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" readonly="readonly">Department on site audits will be conducted every 18 months.This is done in addition to the quarterly data that will be provided by the Access Agencies and aggregated by the department annually.</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">Number and percent of clients who report recieving services as designated in plan of care. Numerator= number of clients reporting services delivered as authorized on plan of care denominator = total number of clients reporting</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">Analyzed collected data (including surveys, focus group, interviews, etc)</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" checked="checked" 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" 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" checked="checked" 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" 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" 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" disabled="disabled" readonly="readonly"></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" checked="checked" 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" checked="checked" 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" readonly="readonly">non representative sample</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" checked="checked" 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" readonly="readonly">contracted Access Agencies</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" checked="checked" 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> <tr ><td > <div style="padding-bottom: 1.5em; width:90%;" > <span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:pmName" class="inputTextPct">Number and percent of clients for whom there is documentation that services were delivered as authorized Numerator=client records indicating services delivered as authorized Denominator= number of records reviewed</span> </div> </div> <table id="svapdxDQ_1:dtPMPrnt_spd: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_spd:1:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Record reviews, on-site</span><div id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct">As part of the required monthly monitoring contact, all clients are asked if services are being delivered as authorized. The record review of a 5% sample of records occurs quarterly.</span></div></div></div><table id="svapdxDQ_1:dtPMPrnt_spd: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_spd:1:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsRpSma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsSaPct" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd: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_spd:1:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsFdMo" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd: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_spd:1:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsFdQu" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxDQ_1:dtPMPrnt_spd: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="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="inputTextarea" readonly="readonly">contracted Access Agency</textarea></span></div></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxDQ_1:dtPMPrnt_spd: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_spd:1:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsFdCo" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsSaOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="inputTextarea" readonly="readonly">supervisory record reviews occur quarterly on a sample of 5% of participants records the Department selects a non-representative sample</textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxDQ_1:dtPMPrnt_spd: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_spd: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_spd: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_spd:1:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxDQ_1:dtPMPrnt_spd: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_spd:1:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:pmDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:pmDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:pmDaFdQu" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:pmDaRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:pmDaRpOthDsc" name="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:pmDaRpOthDsc" class="inputTextarea" readonly="readonly">contracted Access Agency</textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:pmDaFdAn" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd: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_spd:1:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:pmDaFdCo" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd: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_spd:1:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:pmDaFdOt" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:pmDaFdOtDsc" name="svapdxDQ_1:dtPMPrnt_spd:1:svQmPerfMeas:pmDaFdOtDsc" class="inputTextarea" readonly="readonly">DSS on and off site reviews occur every 18 months</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">Number and percent of clients informed of their right to decide between waiver services and institutionalization documented by the participant's signature on the W-889 Informed Consent form. Numerator=number of clients informed of their rights Denominator= total number of clients</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">Off-site record reviews are conducted also</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" 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" 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" checked="checked" 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" checked="checked" 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" readonly="readonly">contracted Access Agencies</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" checked="checked" 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" readonly="readonly">non-representative sample</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" checked="checked" 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" 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> <tr ><td > <div style="padding-bottom: 1.5em; width:90%;" > <span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:pmName" class="inputTextPct">Number and percent of clients educated about the full range of services and choices of providers available as evidenced by their signature on the W-990 form, "Your Rights and Responsibilities." Numerator= total number of client records with evidence of choice of providers Denominator= total number of client records reviewed</span> </div> </div> <table id="svapdxDQ_1:dtPMPrnt_spe: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_spe:1:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Record reviews, on-site</span><div id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct"></span></div></div></div><table id="svapdxDQ_1:dtPMPrnt_spe: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_spe:1:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsSaPct" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe: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_spe:1:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe: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_spe:1:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxDQ_1:dtPMPrnt_spe: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="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="inputTextarea" readonly="readonly">contracted Access Agencies</textarea></span></div></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxDQ_1:dtPMPrnt_spe: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_spe:1:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsFdCo" checked="checked" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsSaOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="inputTextarea" readonly="readonly">non representative sample</textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxDQ_1:dtPMPrnt_spe: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_spe: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_spe: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_spe:1:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxDQ_1:dtPMPrnt_spe: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_spe:1:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:pmDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:pmDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:pmDaFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:pmDaRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:pmDaRpOthDsc" name="svapdxDQ_1:dtPMPrnt_spe:1: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:1:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:pmDaFdAn" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe: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_spe:1:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:pmDaFdCo" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe: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_spe:1:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:pmDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxDQ_1:dtPMPrnt_spe:1:svQmPerfMeas:pmDaFdOtDsc" name="svapdxDQ_1:dtPMPrnt_spe: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="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">Feedback from contracted providers and Department staff is collected through scheduled bi-monthly meetings. There are several levels of record audits and quality improvement/assurance activities that occur. The Access Agencies do supervisory record reviews and also have an external record review process in place as required by their contract with the Department. In addition, the department does a random sample of chart audits on a rotating basis in all of the Access Agencies every 18 months. Client chart audits identify inconsistencies in required documentation and identify trends. A committee, led by the DMHAS APRN Program Director of Geriatric Services, was established to discuss identified mental health issues of waiver clients. As a result, a network of community mental health support services has been established, additional training sessions for care managers have been planned.</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">Individual problems are discovered through chart audits, client satisfaction surveys, reporting of concerns directly from clients, and reporting of individual concerns from access agency staff through the critical incident reporting system. HCBS clinical quality assurance staff are notified of concerns, collect information from other parties involved, and provide oversight and monitoring until satisfactory resolution is achieved. A log of documentation has been maintained to record incidents and identify trends. Identified trends lead to needed procedural changes and influence policy development.</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 will have several options for directing their own services to the extent they are able. If they are unable,they may designate a representative to act on their behalf. Clients may self direct Independent Support Broker service and may choose to be the common law employer with the assistance of a Fiscal Intermediary. For PCA services, the self directed option is available to waiver participants under the Community First Choice state plan option or they may choose a co-employer option by utilizing agencies to secure services. Yet other clients may opt to manage their own services without the assistance of a care manager but in this circumstance,they do not have employer authority. When the Care Manager completes the initial assessment, self directed options are explained as a potential service that the participant may choose. The participant is encouraged to have anyone that they choose present for the assessment. During the assessment process, the participant is supported and encouraged to lead and fully participate in the planning process. Total Plans of Care are signed by the participant, confirming agreement on the plan and a copy is maintained in both the Care Manager and the Alternate Care Unit's file. For participants who choose the common law employer option, the fiscal intermediary (FI) assists with the enrollment process and provides training and support to the participant. The FI describes in detail the participant's responsibility as a household employer and reviews the roles of hiring, recruiting, supervising and managing the service. As part of this process, they advise the participant of the potential liabilities associated with employer authority. For participants who choose the co-employer option, the agency that will provide the worker assists the participant. In both situations, common law and co-employer, the Care Manager may also assist the applicant in understanding the processes and procedures associated with employer authority. Participants have the authority to and are supported to direct and manage their own services to the extent they are able. If they are unable they may appoint a representative to act on their behalf. 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 Independent Support Broker and are responsible for hiring, firing, assignment of duties and signing of time sheets. Supports in these activities are provided to the consumer in a training provided by the contracted fiscal intermediary. 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" 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" checked="checked" 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">When a referral is being made to the waiver program, HCBS Unit staff provide information about the waiver program and services available including self direction opportunities. The Access Agency Care Manager, when completing the initial assessment and in the development of the plan of care, explains opportunities for self direction to the client. Opportunities for self direction in the waiver are both common law employer and co-employer options. Additionally, clients who desire to manage their own service plans, may opt not to have a Care Manager coordinate services for them. In that instance, they do not have employer authority but exercise control over their service plans. If the participant chooses not to self direct services, they can designate someone to act on their behalf. Participants who opt for the common law employer option are assisted by a fiscal intermediary in establishing the status as an employer. The FI provides training to the participant and/or their representative regarding employer responsibilities. The FI describes in detail the participant's responsibility as a household employer and reviews the roles of hiring, recruiting, supervising and managing the employees. As part of this process they advise the participant of the potential liabilities associated with employer authority. Participants may also choose a co-employer option and select workers from provider agencies. The purpose of the two choices is to afford participants options for self direction that they would feel comfortable in assuming.In both cases, the participant may also be assisted and supported in the process by their Care Manager. In addition, the fiscal Intermediary is required to make home visits to waiver participants and provides and reviews an enrollment packet with the participant or their representative that describes their responsibilities as household employers. They also provide step-by-step explanations that include examples of required forms. This includes a review of the roles of recruiting, hiring, supervising, managing and firing of employees. They are also provided information on what the Medicaid agency would consider to be fraudulent billing and includes a brief description of the consequences of such actions.</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" checked="checked" 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">A participant may designate a representative to assist him/her to apply for and utilize the Independent Support Broker Service. The representative may assist with paperwork, make telephone calls and can perform such functions as interviewing, hiring, scheduling and submitting time sheets. A person with a cognitive impairment who lacks the capacity to manage staff shall have a Power of Attorney or conservator to act on their behalf. In all cases, the Care Manager who monitors the overall effectiveness of the Total Plan of Care in meeting the health and safety needs of the participant shall evaluate if the representative is working in the best interest of the participant.</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="225553" 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 bidding 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 is made via direct vendor contract with the fiscal intermediary. The contractor is the same vendor that is used for the Personal Care Assistance waiver for persons under age 65 and for the Community First Choice State Plan option. 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 FTEs required to perform the functions. The payment is made quarterly.</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 worker and problem solving or termination of providers.</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) • A bi-annual survey administered to waiver participants regarding the FMS’ performance • Random audits of Medicaid providers by DSS Quality Assurance Division • Biweekly conference calls by contract manager with the fiscal intermediary to discuss ongoing operations, and review billing issues as well as issues with the consumers and direct care providers.</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, PCA services available under the Community First Choice Option are explained as options depending on the client's identified needs. Care Managers will explain the differences between common law employer and co-employer options. 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.</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="223233" class="noShow" disabled="disabled" readonly="readonly" /><span id="svapdxE1_9:dtPDInfoServices:0:serviceName" class="outputText">Respite</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="223238" class="noShow" disabled="disabled" readonly="readonly" /><span id="svapdxE1_9:dtPDInfoServices:1:serviceName" class="outputText">Chore Services</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="223172" class="noShow" disabled="disabled" readonly="readonly" /><span id="svapdxE1_9:dtPDInfoServices:2:serviceName" class="outputText">Homemaker</span></td> <td class="ctr" ><input id="svapdxE1_9:dtPDInfoServices:2:svcInfoAsst" type="checkbox" name="svapdxE1_9:dtPDInfoServices:2:svcInfoAsst" class="selectBooleanCheckbox" disabled="disabled" /></td> </tr> <tr ><td class="lft" ><input id="svapdxE1_9:dtPDInfoServices:3:rowID" type="text" name="svapdxE1_9:dtPDInfoServices:3:rowID" value="223108" class="noShow" disabled="disabled" readonly="readonly" /><span id="svapdxE1_9:dtPDInfoServices:3:serviceName" class="outputText">Assisted Living</span></td> <td class="ctr" ><input id="svapdxE1_9:dtPDInfoServices:3:svcInfoAsst" type="checkbox" name="svapdxE1_9:dtPDInfoServices:3:svcInfoAsst" class="selectBooleanCheckbox" disabled="disabled" /></td> </tr> <tr ><td class="lft" ><input id="svapdxE1_9:dtPDInfoServices:4:rowID" type="text" name="svapdxE1_9:dtPDInfoServices:4:rowID" value="223180" class="noShow" disabled="disabled" readonly="readonly" /><span id="svapdxE1_9:dtPDInfoServices:4:serviceName" class="outputText">Companion</span></td> <td class="ctr" ><input id="svapdxE1_9:dtPDInfoServices:4:svcInfoAsst" type="checkbox" name="svapdxE1_9:dtPDInfoServices:4:svcInfoAsst" class="selectBooleanCheckbox" disabled="disabled" /></td> </tr> <tr ><td class="lft" ><input id="svapdxE1_9:dtPDInfoServices:5:rowID" type="text" name="svapdxE1_9:dtPDInfoServices:5:rowID" value="223116" class="noShow" disabled="disabled" readonly="readonly" /><span id="svapdxE1_9:dtPDInfoServices:5:serviceName" class="outputText">Home Delivered Meals</span></td> <td class="ctr" ><input id="svapdxE1_9:dtPDInfoServices:5:svcInfoAsst" type="checkbox" name="svapdxE1_9:dtPDInfoServices:5:svcInfoAsst" class="selectBooleanCheckbox" disabled="disabled" /></td> </tr> <tr ><td class="lft" ><input id="svapdxE1_9:dtPDInfoServices:6:rowID" type="text" name="svapdxE1_9:dtPDInfoServices:6:rowID" value="225553" class="noShow" disabled="disabled" readonly="readonly" /><span id="svapdxE1_9:dtPDInfoServices:6:serviceName" class="outputText">Independent Support Broker</span></td> <td class="ctr" ><input id="svapdxE1_9:dtPDInfoServices:6:svcInfoAsst" type="checkbox" name="svapdxE1_9:dtPDInfoServices:6:svcInfoAsst" class="selectBooleanCheckbox" disabled="disabled" /></td> </tr> <tr ><td class="lft" ><input id="svapdxE1_9:dtPDInfoServices:7:rowID" type="text" name="svapdxE1_9:dtPDInfoServices:7:rowID" value="223130" class="noShow" disabled="disabled" readonly="readonly" /><span id="svapdxE1_9:dtPDInfoServices:7:serviceName" class="outputText">Environmental Accesibility Adaptations</span></td> <td class="ctr" ><input id="svapdxE1_9:dtPDInfoServices:7:svcInfoAsst" type="checkbox" name="svapdxE1_9:dtPDInfoServices:7:svcInfoAsst" class="selectBooleanCheckbox" disabled="disabled" /></td> </tr> <tr ><td class="lft" ><input id="svapdxE1_9:dtPDInfoServices:8:rowID" type="text" name="svapdxE1_9:dtPDInfoServices:8:rowID" value="223199" class="noShow" disabled="disabled" readonly="readonly" /><span id="svapdxE1_9:dtPDInfoServices:8:serviceName" class="outputText">Mental Health Counseling</span></td> <td class="ctr" ><input id="svapdxE1_9:dtPDInfoServices:8:svcInfoAsst" type="checkbox" name="svapdxE1_9:dtPDInfoServices:8:svcInfoAsst" class="selectBooleanCheckbox" disabled="disabled" /></td> </tr> <tr ><td class="lft" ><input id="svapdxE1_9:dtPDInfoServices:9:rowID" type="text" name="svapdxE1_9:dtPDInfoServices:9:rowID" value="226274" class="noShow" disabled="disabled" readonly="readonly" /><span id="svapdxE1_9:dtPDInfoServices:9:serviceName" class="outputText">Personal Care Assistant</span></td> <td class="ctr" ><input id="svapdxE1_9:dtPDInfoServices:9:svcInfoAsst" type="checkbox" name="svapdxE1_9:dtPDInfoServices:9:svcInfoAsst" class="selectBooleanCheckbox" disabled="disabled" /></td> </tr> <tr ><td class="lft" ><input id="svapdxE1_9:dtPDInfoServices:10:rowID" type="text" name="svapdxE1_9:dtPDInfoServices:10:rowID" value="223140" class="noShow" disabled="disabled" readonly="readonly" /><span id="svapdxE1_9:dtPDInfoServices:10:serviceName" class="outputText">Transportation</span></td> <td class="ctr" ><input id="svapdxE1_9:dtPDInfoServices:10:svcInfoAsst" type="checkbox" name="svapdxE1_9:dtPDInfoServices:10:svcInfoAsst" class="selectBooleanCheckbox" disabled="disabled" /></td> </tr> <tr ><td class="lft" ><input id="svapdxE1_9:dtPDInfoServices:11:rowID" type="text" name="svapdxE1_9:dtPDInfoServices:11:rowID" value="223153" class="noShow" disabled="disabled" readonly="readonly" /><span id="svapdxE1_9:dtPDInfoServices:11:serviceName" class="outputText">Assistive Technology</span></td> <td class="ctr" ><input id="svapdxE1_9:dtPDInfoServices:11:svcInfoAsst" type="checkbox" name="svapdxE1_9:dtPDInfoServices:11:svcInfoAsst" class="selectBooleanCheckbox" disabled="disabled" /></td> </tr> <tr ><td class="lft" ><input id="svapdxE1_9:dtPDInfoServices:12:rowID" type="text" name="svapdxE1_9:dtPDInfoServices:12:rowID" value="225399" class="noShow" disabled="disabled" readonly="readonly" /><span id="svapdxE1_9:dtPDInfoServices:12:serviceName" class="outputText">Recovery Assistant</span></td> <td class="ctr" ><input id="svapdxE1_9:dtPDInfoServices:12:svcInfoAsst" type="checkbox" name="svapdxE1_9:dtPDInfoServices:12:svcInfoAsst" class="selectBooleanCheckbox" disabled="disabled" /></td> </tr> <tr ><td class="lft" ><input id="svapdxE1_9:dtPDInfoServices:13:rowID" type="text" name="svapdxE1_9:dtPDInfoServices:13:rowID" value="225398" class="noShow" disabled="disabled" readonly="readonly" /><span id="svapdxE1_9:dtPDInfoServices:13:serviceName" class="outputText">Bill Payer</span></td> <td class="ctr" ><input id="svapdxE1_9:dtPDInfoServices:13:svcInfoAsst" type="checkbox" name="svapdxE1_9:dtPDInfoServices:13:svcInfoAsst" class="selectBooleanCheckbox" disabled="disabled" /></td> </tr> <tr ><td class="lft" ><input id="svapdxE1_9:dtPDInfoServices:14:rowID" type="text" name="svapdxE1_9:dtPDInfoServices:14:rowID" value="225397" class="noShow" disabled="disabled" readonly="readonly" /><span id="svapdxE1_9:dtPDInfoServices:14:serviceName" class="outputText">Chronic Disease Self-Management Program</span></td> <td class="ctr" ><input id="svapdxE1_9:dtPDInfoServices:14:svcInfoAsst" type="checkbox" name="svapdxE1_9:dtPDInfoServices:14:svcInfoAsst" class="selectBooleanCheckbox" disabled="disabled" /></td> </tr> <tr ><td class="lft" ><input id="svapdxE1_9:dtPDInfoServices:15:rowID" type="text" name="svapdxE1_9:dtPDInfoServices:15:rowID" value="223092" class="noShow" disabled="disabled" readonly="readonly" /><span id="svapdxE1_9:dtPDInfoServices:15:serviceName" class="outputText">Adult Day Health</span></td> <td class="ctr" ><input id="svapdxE1_9:dtPDInfoServices:15:svcInfoAsst" type="checkbox" name="svapdxE1_9:dtPDInfoServices:15:svcInfoAsst" class="selectBooleanCheckbox" disabled="disabled" /></td> </tr> <tr ><td class="lft" ><input id="svapdxE1_9:dtPDInfoServices:16:rowID" type="text" name="svapdxE1_9:dtPDInfoServices:16:rowID" value="225396" class="noShow" disabled="disabled" readonly="readonly" /><span id="svapdxE1_9:dtPDInfoServices:16:serviceName" class="outputText">Care Transitions</span></td> <td class="ctr" ><input id="svapdxE1_9:dtPDInfoServices:16:svcInfoAsst" type="checkbox" name="svapdxE1_9:dtPDInfoServices:16:svcInfoAsst" class="selectBooleanCheckbox" disabled="disabled" /></td> </tr> <tr ><td class="lft" ><input id="svapdxE1_9:dtPDInfoServices:17:rowID" type="text" name="svapdxE1_9:dtPDInfoServices:17:rowID" value="223227" class="noShow" disabled="disabled" readonly="readonly" /><span id="svapdxE1_9:dtPDInfoServices:17:serviceName" class="outputText">Adult Family Living/Foster Care</span></td> <td class="ctr" ><input id="svapdxE1_9:dtPDInfoServices:17:svcInfoAsst" type="checkbox" name="svapdxE1_9:dtPDInfoServices:17:svcInfoAsst" class="selectBooleanCheckbox" disabled="disabled" /></td> </tr> <tr ><td class="lft" ><input id="svapdxE1_9:dtPDInfoServices:18:rowID" type="text" name="svapdxE1_9:dtPDInfoServices:18:rowID" value="223097" class="noShow" disabled="disabled" readonly="readonly" /><span id="svapdxE1_9:dtPDInfoServices:18:serviceName" class="outputText">Personal Emergency Response Systems</span></td> <td class="ctr" ><input id="svapdxE1_9:dtPDInfoServices:18:svcInfoAsst" type="checkbox" name="svapdxE1_9:dtPDInfoServices:18:svcInfoAsst" class="selectBooleanCheckbox" disabled="disabled" /></td> </tr> <tr ><td class="lft" ><input id="svapdxE1_9:dtPDInfoServices:19:rowID" type="text" name="svapdxE1_9:dtPDInfoServices:19:rowID" value="223164" class="noShow" disabled="disabled" readonly="readonly" /><span id="svapdxE1_9:dtPDInfoServices:19:serviceName" class="outputText">Care Management</span></td> <td class="ctr" ><input id="svapdxE1_9:dtPDInfoServices:19:svcInfoAsst" type="checkbox" name="svapdxE1_9:dtPDInfoServices:19: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 contracted fiscal intermediary is also responsible for the oversight and support of participant self-direction: • The fiduciary supports are procured and compensated through competitively bid contracts. • After assessment by the Care Manager and approval for waiver services, the FI 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 FI 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 fiduciary for payment. • The FI 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" checked="checked" 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" 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"></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">The Care Manager assists the client with the selection of services as an alternative to participant directed services if the participant chooses to terminate the self directed services. The Care Manager discusses with the individual/family all the available options and resources available, updates the total plan of care and begins the process of referral to those options. Once the new options have been identified and secured, the care manager is responsible for ensuring a seamless transition for the participant. A wide range of services are available under the waiver that do not require the participant to self direct if they choose not to.</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">Each individual who self-directs by hiring his or her own workers has been trained by the fiscal intermediary that has also described the expectations of the participant. Termination of the participant’'s self-direction opportunity may be made when a participant or representative cannot adhere to the terms of the Agreement to participate in self direction. Key terms are: 1. To participate in the development and implementation of the plan of care. 2. To actively participate in the selection and ongoing monitoring of supports and services. 3. To understand that no one can be both a paid employee and the employer of record. 4. To authorize payments for services provided only to the recipient according to the individual plan. 5. To enter into an agreement with the provider agency/agencies or individual support worker(s) hired. 6. To submit time sheets to the fiscal intermediary on a weekly basis or within the agreed upon timeframe. 7. To participate in the Department’'s quality review process. 8. To use qualified vendors enrolled by the Department. 9. To ensure that each employee has read the required training materials and completed any individual specific training in the total plan of care prior to working with the person. 10. To not offer employment to any new employee until the criminal history background check has been completed. 11. To notify the Care Manager when the individual is no longer able to meet the responsibilities for self-directed services. The individual acknowledges that the authorization and payment for services that are not rendered could subject him/her to Medicaid fraud charges under State and federal law. Breach of any of the above requirements with or without intent may disqualify the individual from self-directing services. Violations will result in training and warnings, until a consistent pattern of non-compliance could be documented. Intentional fraud is the only instance anticipated where involuntary termination of an individual from self-direction would be immediate. Self directed services can be terminated if the participant does not comply with the agreed upon requirements. The care manager would coordinate the transition of services and assist the individual to choose a qualified provider to replace the directly hired staff, make the referrals to the new providers and ensure the seamless transition of services for the waiver participant. Participant direction of self directed waiver services can be involuntarily terminated when a participant does not demonstrate the ability to manage his or her own PCAs and will not appoint a representative. The first option that would be explored would be whether other, non self directed, services could be utilized to meet the participant's identified needs. If a service plan could not be developed to meet the identified needs, a Notice of Action would be issued and the participant would then have the right to a fair hearing pursuant to Medicaid law. The care manager would have the responsibility to coordinate the transition of services from self directed to provider based services in a manner that would ensure a smooth transition for the participant.</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="52" 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="55" 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="59" 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="62" 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="64" 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" checked="checked" 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">Agencies with choice would function as the managing provider for PCA services. The agencies might be Homemaker/Companion Agencies or Home Health Agencies. The agency would be responsible for locating appropriate providers who could meet the service requirements of the participant. They would also be responsible to arrange for a back up provider should the scheduled PCA be unavailable. The agency would provide the participant the opportunity to meet and interview several potential PCAs and would allow the participant to choose which provider is the "best fit." Participants may also choose to continue to receive the care management service so that the care manager can assist in advocating for the participant's right to self determine.</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" checked="checked" 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 performs this function on behalf of the participant. The cost is included in their administrative reimbursement.</textarea></span> </div> </div> <div class="checkboxGroup"> <input id="svapdxE2_1:dosStfAddQual" type="checkbox" name="svapdxE2_1:dosStfAddQual" checked="checked" 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" checked="checked" 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" checked="checked" 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" checked="checked" 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" checked="checked" 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 participants under this Waiver may request and receive a fair hearing in accordance with DSS' Medical Assistance Program. Applicants will receive a copy of the DSS W-889 Informed Consent Form and W-990, Your Rights and Responsibilities, during the first visit with the Care Manager. Participants are eligible for Fair Hearings in the following circumstances: Participant was not offered the choice of home and community services as an alternative to institutional care; DSS does not reach a determination of financial eligibility within standards of promptness; DSS denies the application for the individual not meeting the level of care or other eligibility criteria; DSS disapproves the individual'’s Plan of Care; DSS denies or terminates a service of the individual'’s choice; DSS denies or terminates a payment to a provider of the individual'’s choice; or DSS discharges an individual from this Waiver. In accordance with Connecticut Medicaid rules, a Notice of Action (NOA) will be sent to a Waiver participant when any service is denied, reduced, suspended or terminated. The NOA and Freedom of Choice/Fair Hearing Notification will be provided in Spanish to support providing persons with LEP or non-English proficiency. Per the Department of Social Services Uniform Policy Manual (UP-91-8 1570.20), the Department does not terminate or reduce the client's benefits until the Fair Hearing decision is reached if the client requests a Fair Hearing within the 10 day notice period. The client's benefits remain the same pending the Fair Hearing decision. Per DSS Uniform Policy Manual (UP-91-32 1570.10), the Department mails or gives adequate notice at least ten days prior to the date of the intended action if the Department intends to discontinue, terminate, suspend, or reduce benefits. The only exceptions to this policy are if the client dies or state or federal law supersede the Department's policy to continue benefits while awaiting a Fair Hearing decision. The Department issues and publicizes all Fair Hearing policies and procedures in all client correspondence. At the time of application and at the time of any action affecting the client's benefits, the Department informs the client, in writing, of the right to a Fair Hearing; how the client can request a Fair Hearing; and that the requester may be self-representative, may use legal counsel, a relative, friend, or other spokesperson and is provided with contact information for the local Legal Aid office. Form W-1513 is an example of a form used by the CT Home Care Program for Elders that provides detailed instructions for requesting a fair hearing in English and in Spanish. The Office of Legal Counsel, Regulations and Administrative Hearings, the client and the Alternate Care Unit receive copies of documentation related to the Fair Hearing. Copies are kept on file with the Office of Legal Counsel, Regulations and Administrative Hearings as well as in the client's chart. The client is informed in writing of the outcome of the fair hearing.</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">Connecticut employs strict protocols regarding the reporting of abuse, neglect, and exploitation. DSS has demanding and prescriptive procedures for incident and management reporting systems. These procedures are dictated by State statute and regulation. The objective is to identify, address and seek to prevent instances of abuse, neglect and exploitation. See the overview below for a summary of DSS procedures. Overview Persons served by this waiver are under the authority of the PSE Statute 17b-450-461 for Elders. Mandadory reporting is required for serious incidents which are defined as involving abuse/neglect or other imediate risk. Mandated reporters include all staff employed directly by client, provider or agency, including Care Manager and central office staff. In addition, clergy, police officers, social workers, medical professionals and nursing home staff are mandatory reporters for elders. An electronic system has been developed to receive and process information regarding critical incidents. A user guide has been developed to assist mandated reporters in making reports into the Ascend system: Critical Incident Reporting Policy and Procedure The purpose of Critical Incident reporting is to document, evaluate and monitor serious or severe occurrences that affect the well-being of CHC clients. A Critical Incident is an actual or alleged event, incident or course of action involving the perceived or actual threat to a client&#8217;s health, welfare or ability to remain in the community. It is the responsibility of the care manager or other staff person that discovers the critical incident or has knowledge of the critical incident to investigate and report the alleged critical incident to ACU using the Ascend online system. When reporting a critical incident, be prepared to provide enough information so the reviewer knows: &#8226; Who was involved in the inciden? &#8226; What were the circumstances of the incident - details &#8226; Where the incident happened &#8226; When the incident took place, date and time &#8226; What provider agency was involved (drop down box) The report should provide enough detail to understand the circumstances of the incident, document the steps taken to respond to the incident, identify how the client&#8217;s safety has been addressed, the follow-up measures taken and/or planned, and document whether mandatory reporting has occurred. Additional follow-up will be required when the report lacks sufficient information for the reviewer to understand the nature of the incident, how a client or situation has been stabilized, what safety measures have been taken to investigate and remedy the circumstances. ACU should be notified if it appears that a more formal investigation of the provider agency is warranted. Critical incidents should be reported using the Ascend website https://www.ascendami.com/CTHomeCareForElders/SharedFiles/CriticalIncident.aspx?ddmkey=kOfDQfA1U/e5kyikGdPaoOknWCbmxnlwcisCIRcjjh7D3VAiWvqsfw7Da970U+vfFagSbapDm94GpiSDGWTmdQ==. All requested data should be entered and accompanying narrative should be as specific as possible. It is expected that critical incident reports will be made within 2 business days from occurrence. The following incidents must be reported: Unexpected Absence of the Primary Caregiver Any event that results in the client's inability to receive services that places his or her health or safety at risk. This includes involuntary termination by the provider agency and failure of the client's back up plan. This occurs when the primary caregiver becomes ill, calls out sick, does not report to client&#8217;s home for duty, experiences a family emergency, other circumstance. The narrative should document the occurrence, name of caregiver, reason for absence, agency, and any adverse events that may have resulted from the incident. Unexpected absences should only be reported when they present specific risks to health and safety. There is no need to report every caregiver who fails to show up for their shift. Untimely Death The client dies unexpectedly from either natural causes, accident, alleged caregiver malpractice, or suspected criminal action. This does not include deaths that can be anticipated such as terminal illness. The narrative should include the cause of death, if known, circumstances such as who reported the death, involvement of law enforcement, and other pertinent information. Emergency Room Visit or Unplanned Hospitalization Incidents should be documented when there is an emergency room visit or hospitalization four times or more within a six month period. This will help to detect potential preventive measures or identify medical interventions that may prevent unnecessary use of emergency room or hospital inpatient stays. The narrative should state date, distinguish between hospitalization or emergency room visit, which facility utilized and diagnosis. Once reported, the clock resets and the following four or more in six months is then reported. Scheduled hospitalizations should not be reported. Suicide Attempt All actual or suspected suicide attempts must be reported and followed up by appropriate intervention and linkage with mental health services. Suicidal threats or ideation would not be documented in this area. Serious Criminal Allegation &#8211; Client as Victim Any action committed against the client that could result in arrest and/or incarceration of an alleged perpetrator must be reported, followed up by appropriate law enforcement intervention, with client&#8217;s or authorized representative&#8217;s permission. Serious Criminal Allegation &#8211; Client as Perpetrator Client is the alleged perpetrator of criminal activity that may result in client&#8217;s arrest and/or incarceration. If client has assaulted a paid caregiver, narrative should describe the alleged criminal action, intervention, safety strategy and results. Allegations of Abuse, Neglect, Exploitation Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse can include sexual assault, physical assault, verbal abuse, rape. Neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect can include insufficient staffing; staff not performing assigned tasks; care not being given by family or others who have agreed to provide support; self-neglect (refuses food, hygiene, medications including substance abuse and dangerous behavior); refuses necessary services; residential environments that may create a threat to life, health or safety such as lack of repairs, heat, hot water, electricity, unsanitary or toxic conditions. Exploitation is the misappropriation of property, the deliberate misplacement of client&#8217;s property, or wrongful, temporary or permanent use of a client&#8217;s belongings or money without the client&#8217;s consent; deliberate damage, destruction, theft, misplacement or use of a client&#8217;s belongings or money without the client&#8217;s consent, including the deliberate diversion of medications. Narratives should be clear and contain sufficient detail about who was involved, provider agency, request for and results of provider agency investigation, name of alleged perpetrator, description of what happened, actions taken, notification of or involvement with Protective Services for the Elderly, Law Enforcement, changes in care plans, referrals to other services as needed. Restraint: A restraint is any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a client to move his or her arms, legs, body, or head freely or a drug or medication when it is used as a restriction to manage the client's behavior or restrict the client's freedom of movement and is not a standard treatment or dosage for that clients condition. Seclusion: the involuntary confinement of a client alone in a room or an area from which the client is physically prevented from leaving. Seclusion may also be used for the management of violent or destructive behavior. Other Describe any other incident that poses a risk to the client&#8217;s health or safety in the space provided. For DSS Internal Review &#8220;Recommendations for waiver or system change -In the agency&#8217;s internal review of this event, are there any recommendations offered to improve the quality of care for other waiver participants or changes in policy/procedure? If so, summarize the recommendations/changes and the plans for implementation.&#8221; ACU staff may notice patterns from data reporting that emerge as a widespread systemic problem or may suggest the need for programmatic changes. All members of the participant's care planning team, support staff and service agency staff members are required to report critical incidents. Recipients of Critical Incident reporters include: Participant's Care Manager Participant and/or Conservator DSS Quality Assurance Staff Participant's Provider. Response to Serious Events All State departments involved with HCBS waivers initiate investigations of any serious issues. Other parties are contacted and interviewed as appropriate. If a concern were raised about any matter that has come up while the consumer was under the support of a provider, the provider would be required to submit an incident report. The specific manner of follow-up for such concerns is determined by the nature of the allegation and the results of the investigation. Possible actions include the suspension or removal of a provider from the active registry/approved provider list or reporting to law enforcement or licensure agencies (e.g., Department of Public Health). Action to ensure the safety of a participant who is at imminent risk occurs immediately (removal of provider and replacement with equivalent service provider). Additional follow-up with other entities include but are not limited to DSS units/divisions (e.g., Quality Assurance, Medical Policy, Legal), law enforcement, Department of Public Health may be necessary. When a participant in this waiver is a victim of abuse, neglect or exploitation, a referral to Protective Services for Elders is made. The care manager is responsible for ensuring that the report is made. 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. Abuse and Neglect For persons aged 60 or older, Section 17b-451 of the Connecticut General Statutes requires medical professionals, social workers, police officers, clergy, and nursing home staff to report to the Department of Social Services any knowledge or suspicion of abuse, neglect, exploitation, or abandonment. In addition, friends, neighbors, family members, and acquaintances who suspect an elderly person is being abused, neglected, or exploited may call the closest office of the Department of Social Services. Critical incident reporting comes to quality assurance clinical staff members who handle quality assurance for this waiver. At this time, a Licensed Clinical Social Worker and a Health Program Supervisor receive and document all reported critical events or incidents. Reports are reviewed upon receipt and responses are tracked. Staff members also confer with the Protective Services Manager when needed. The Ascend data base is maintained and analysis is done for trends. Policies and procedures are developed in response to identified trends and utilized to prevent reoccurrence. Problematic situations are monitored and addressed on an individual and ongoing basis as needed. The PSE worker is required to provide a written status report using DSS form W-917 regarding the disposition of the case within 5 working days of the completion of the investigation. DSS quality assurance staff monitors the situation until satisfactory resolution is reached. The Department quality assurance staff consisting of a Licensed Clinical Social Worker and a Health Program Supervisor oversees the critical incident reporting system and coordinates activities with Protective Services for Elders.</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">Training is provided to all participants and involved family or other unpaid caregivers via Care Managers on 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. Identification and the prevention of neglect, abuse and exploitation is a standard component of Care Manager orientation and training. Upon assessment, when services are initiated, and on an ongoing basis, no less than monthly contact, participants and caregivers are given training as teaching opportunities arise. Protective Services for Elders has a statewide toll-free number for reporting abuse, neglect and exploitation. Infoline 211 handles after hours reports. DSS publishes a brochure on PSE reporting.</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">Critical incident reporting comes to quality assurance staff, a Health Program Supervisor and a Licensed Clinical Social Worker who receive all reported critical events or incidents through the Ascend on-line system. Reports are reviewed upon receipt and responses are tracked. The Nurse Consultant is also the unit's liaison with the Protective Services Manager. A database is maintained within ACU and analysis is done for trends. Policies and procedures are developed in response to identified trends and utilized to prevent reoccurrence. Problematic situations are monitored and addressed on an individual and ongoing basis as needed. Any suspected abuse, neglect, exploitation and/or abandonment of home care program clients is mandated for report to Elderly Protective Services. Appropriate referrals will be initiated via telephone within 72 hours of suspecting that an elder has been abused, neglected and/or exploited. The telepohne report is followed up with a written referral using the DSS form W-675 within 5 working days. A written copy of all referrals made to PSE by care managers or ALSA staff shall be sent to DSS ACU Health and Safety Nurse Consultant. PSE will investigate and determine whether substantiation should occur. The PSE worker is required to provide a written status report using DSS form W-917 regarding the disposition of the case within 5 working days of the completion of the investigation. DSS quality assurance staff monitor the situation until satisfactory resolution is reached and share the outcome with the care manager, client and/or their representative generally within 24 hours of receiving the information.</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">The Department quality assurance staff consisting of a Health Program Supervisor and Licensed Clinical Social Worker oversees the critical incident reporting system and coordinates activities with Protective Services for Elders. The critical incident reports are available on the Ascend on-line system immediately. Quality Assurance Staff monitor the critical incident queue on a daily basis and can respond immediately upon receiving the report. Quality Assurance Staff review the report and may request more information, follow up, reports on provider agency investigations of alleged abuse, neglect or exploitation. The type of incidents that are reported are as follows: unexpected absence of the primary caregiver; untimely death; emergency room visit or unplanned hospitalization; suicide attempt; serious criminal allegation -client as victim; serious criminal allegation - client as perpetrator; allegations of abuse, neglect, or exploitation of client; fire in residence with significant risk to client; missing person reported to police; misappropriation of client's funds; seclusion; restraint; and other situations that fall outside of these categories. DSS Quality Assurance staff may conduct an internal review to make recommendations for system change. In the agency&#8217;s internal review of this event, recommendations may be offered to improve the quality of care for other waiver participants or changes in policy/procedure.</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">DSS investigates cases of abuse, neglect, abandonment and exploitation of the elderly and the disabled as noted above. Suspected use of restraints or seclusion which occurs in the home or community is reported to the state's 24-hour abuse hotline and investigations are completed within 24 hours or less. DSS also investigates complaints and incidents where restraints or seclusion are used in institutional settings. Investigation may be delegated to the Care Manager or conducted jointly with ACU staff. The use of restraints or seclusion is not allowed in the State of Connecticut. Care manager visits, observation and interview is the methodology utilized to detect any unauthorized use of restrictive interventions or seclusion used for home care clients. The state is developing a new universal assessment tool based on the interRAI model. The tool is developed and training has been initiated. Questions are included in the assessment regarding the use of restraints, restrictive interventions and seclusion.</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">DSS is responsible for investigating reports of abuse, neglect, abandonment and exploitation of the elderly and the disabled. Incidents of restrictive interventions which occur in the home or community are reported to the state's 24-hour abuse hotline and investigations are completed within 24 hours or less. Incidents which occur in institutional facilities would also be investigated by DSS as well. Investigations may be delegated to the Care Managers or conducted jointly with the ACU staff. Care manager visits, observation and interview is the methodology utilized to detect any unauthorized use of restricitve interventions used for home care clients. The state is developing a new universal assessment tool based on the interRAI model. The tool is developed and training has been initiated. Questions are included in the assessment regarding the use of restraints, restrictive interventions and seclusion.</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">DSS is responsible for investigating reports of abuse, neglect, abandonment and exploitation of the elderly and the disabled. Incidents of seclusion which occur in the home or community are reported to the state's 24-hour abuse hotline and investigations are completed within 24 hours or less. Incidents which occur in institutional facilities would also be investigated by DSS as well. Investigations may be delegated to the Care Managers or conducted jointly with the ACU staff. Care manager visits, observation and interview is the methodology utilized to detect any unauthorized use of restricitve interventions used for home care clients. The HCBS unit also has modified its critical incident reporting form to include reporting of incidents of restraints, seclusion or restrictive interventions. Incident reports will be compared to reports created from the assessment and reassessment that specifically asks these questions. The state is developing a new universal assessment tool based on the interRAI model. The tool is developed and training has been initiated. Questions are included in the assessment regarding the use of restraints, restrictive interventions and seclusion.</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">The number and percent of critical incidents regarding waiver participants requiring investigation by Protective Services for Elders Numerator= total number of incidents reported to PSE Denominator= total number of cases requiring reporting to PSE</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">Critical events and incident reports</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" checked="checked" 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" readonly="readonly">contracted access Agency</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" 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" checked="checked" 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" readonly="readonly">contracted Access Agency</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 clients who express that service providers are kind and respectful. Numerator= number of clients who express that providers are respectful Denominator= number of clients surveyed</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">Analyzed collected data (including surveys, focus group, interviews, etc)</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"></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" checked="checked" 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" 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" checked="checked" 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" checked="checked" 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">Access agency</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" checked="checked" 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" 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" checked="checked" 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" readonly="readonly">10% sample</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" checked="checked" 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">Access Agency</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" checked="checked" 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" 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 participant records that indicate the participant has been apprised of their Rights and Responsibilities as evidenced by DSS form W-990 in participant's record. Numerator=number of records that have W-990 form Denominator= number of records reviewed</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">Off-site record reviews are also conducted by Department staff</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" 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" checked="checked" 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" checked="checked" 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" readonly="readonly">Access Agency</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" checked="checked" 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" readonly="readonly">non respresentative sample done by DSS staff also Access Agency supervisory record reviews are done quarterly on 5% of the the clients</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" checked="checked" 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" readonly="readonly">Access agency</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> <tr ><td > <div style="padding-bottom: 1.5em; width:90%;" > <span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:pmName" class="inputTextPct">Number and percent of critical incident reports that are submitted to the HCBS unit within 48 hours as required by the waiver Numerator= number of critical incidents reported timely Denominator= number of critical incidents reported</span> </div> </div> <table id="svapdxGQ_1:dtPMPrntHW: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="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Critical events and incident reports</span><div id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct"></span></div></div></div><table id="svapdxGQ_1:dtPMPrntHW: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="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsSaPct" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:3: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:3:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxGQ_1:dtPMPrntHW: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="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="inputTextarea" readonly="readonly">Access Agency</textarea></span></div></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxGQ_1:dtPMPrntHW: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="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsFdCo" checked="checked" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsSaOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxGQ_1:dtPMPrntHW: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="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxGQ_1:dtPMPrntHW: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="svapdxGQ_1:dtPMPrntHW: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="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxGQ_1:dtPMPrntHW: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="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:pmDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:pmDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:pmDaFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:pmDaRpOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:pmDaRpOthDsc" name="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:pmDaRpOthDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:pmDaFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW: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="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:pmDaFdCo" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW: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="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:pmDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxGQ_1:dtPMPrntHW:3:svQmPerfMeas:pmDaFdOtDsc" name="svapdxGQ_1:dtPMPrntHW:3: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 critical incidents that are individually addressed as specified in the waiver application Numerator = number of incidents addressed as specified in the waiver Denominator=total number of incidents reported</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">Critical events and incident reports</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"></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" checked="checked" 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" 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" disabled="disabled" readonly="readonly"></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> </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 cases of restraints or seclusion that are reported via the critical incident system. Numerator= number of critical incidents of restraints and seclusion Denominator = number of incidents of restraints and seclusion</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">Other</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">Assessment data</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" checked="checked" 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" checked="checked" 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" 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">Critical events and incident reports</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"></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" checked="checked" 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" checked="checked" 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" 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" disabled="disabled" readonly="readonly"></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" 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" 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 receiving age appropriate preventive care. Numerator = number of clients receiving preventive care Denominator= 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">Assessment data</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" checked="checked" 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" checked="checked" 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" 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" disabled="disabled" readonly="readonly"></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" 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> </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> </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">The Department holds Access Agency meetings bi-monthly for the purpose of disseminating information and dicussing issues of concern. Both Access Agencies and The Department staff conduct client satisfaction surveys to elicit client feedback regarding health and safety issues. Elder Protective Services, Alternate Care Unit and Access Agencies collaborate to identify and resolve health and safety concerns. The Quality Assurance Staff have ongoing consultation and dialogue with the Protective Services for elders manager as needed on case by case basis. In addition the Quality Assurance Committee, consisting of DSS staff and representatives from all of the Access Agencies meet on a regular basis. One of the outcomes of this collaboration was the development of a new, updated policy on critical incident reporting.</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">A committee of care managers, clinical staff and quality assurance staff convened to update the assessment instrument for collection of data related to health promotion, chronic disease management, and to implement best practices. Discussions between access agencies, PSE and ACU staff with respect to informed risk versus self determination, i. e. what is an acceptable level of risk to both the client and the program. All findings related to participant safeguards are entered into a data base within the Alternate Care Unit. Communications occur with the care manager and other Access Agency staff as appropriate for any corrective action or interventions. Access Agency staff monitor the waiver participants on a monthly basis and will continue to follow up on the identified problem as needed.</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">contracted access agency</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">Health standard monitoring is in place at the Access Agency level. Data aggregation and reports including analysis for trending of this information is housed in the Ascend on-line system.. The assessment tool is being modified and is going live in July 2015. All assessment and reassessment data is currently transferred to the Department on a semi-annual basis by the Access Agencies. Health promotion and prevention questions have been added to the new Universal Assessment Instrument. Reports on this data will be available on the new Balancing Incentive Program website. New guidelines for collaborative efforts among access agencies, HCBS unit and Protective Services for Elders have been developed and implemented.</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">The State of Connecticut has been utilizing a comprehensive system of checks and balances in order to establish consistent quality assurance within services provided to clients through this waiver. The state has been guided by state and federal regulations to assist in establishing procedures and the many varied data collection, agregation and analysis processes that are currently utilized. Through the productive process of analysis, discovery, remediation and improvement, the state recognizes the benefit to client services that can be obtained through some system design changes. Currently, statewide chart audits of Access Agency clients are conducted quarterly. We have also added a reporting requirement for the Access Agencies to provide a summary report of supervisory record reviews done on a regular basis. The Department increased the sampling size of ALSA onsite record reviews to monitor improvement as a result of the collaborative efforts of the Department and the ALSA Association. Onsite reviews are conducted of 100% of ALSA facilities identified as problematic. A tool was developed for Access Agency supervisors to complete when conducting supervisory record reviews, and its use has been implemented. Data is aggregated and adjustments are made to the tool as necessary. Hewlett Packard Enterprises (HP) will be providing a report to the Department to provide data on the difference between services authorized and services actually delivered sorted by service type. This will allow for an analysis of trends and targeted remediation. This will be reported annually beginning SFY 2015. The State of Connecticut contracts with HP to employ a data system to ensure reimbursement is consistent with waiver requirements. The provider relations unit oversees the contract with HP, as part of the medical operations process. They can make changes to procedure codes, edits and audits. Clients are identified by Medical Eligibility or Benefit Plan code. Providers are based on type and specialty. The system is designed to make sure it can be billed only for what is allowed through the edits and audits system. In addition, HP developed a care plan portal in which the Access Agency Care Managers enter the client&#8217;s care plan and prior authorization for services including date spans, number of units, authorized provider so that the providers can only bill what is authorized in the care plan.</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" 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" checked="checked" 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" checked="checked" 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">Contracted Access Agencies, ALSA facilities</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">Continuous and Ongoing</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">Our current process for monitoring client service quality standards is through Access Agency client record audits in each of the five state regions. DSS quality assurance clinical staff review each chart using a developed tool to measure complinace with documention required through contracts and regulations. Trending of information is gleaned from tools used. ACU staff members meet with Access Agency Supervisory staff to discuss findings. A formal report is generated to the Access Agencies reflecting findings and recomendations for remediation. Access Agencies respond in writing with a plan of correction including timetables and process for implementation of improvements. DSS utilizes the web-based critical incident reporting system whch allows for aggregation of data and has enhanced our ability to produce summary reports, detect trends and identify areas for improvement.</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">Evaluation of the Quality Improvement Strategy is continuous and ongoing. As reports from the Alternate Care Unit quality assurance staff are generated on all of the aggregated, analyzed data, they are scrutinized for trends and potential process improvements. Ongoing dialog and opportunities for improved collaboration have been established in order to better serve this state's elder population. A QA workgroup composed of ACU staff and Access Agency Clinical Supervisors has been initiated to address ongoing QA/QI activities. This work group meets on a bi-monthly basis.</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 Auditors of Public Accounts monitor state agencies regarding fiscal and compliance matters. Auditors provide independent, unbiased and objective opinions and recommendations on the operation of state agencies and effectiveness in safeguarding resources. Financial compliance auditing is the principal responsibility plus an examination of performance in order to determine the effectiveness of an agency in achieving its expressed legislative purpose. The Performance Audit Team devotes its time mainly to performance auditing, focusing on particular programs administered by a state agency. Findings are reported and discrepancies are identified and presented to the program and/or the provider. The Auditors follow up to make sure that changes are made to achieve compliance with state and federal regulations. The Department's Quality Assurance Unit conducts annual onsite provider audits to ensure that state and federal funds are being expended appropriately. Financial statements, paid claims data, and other material are reviewed to assure that services were rendered and the agency is compliant with federal and state regulations and to detect fraud. Providers who are found out of compliance may be fined, terminated from the Medicaid program as a provider or given recommendations for improvement to achieve compliance. The Office of Quality Assurance conducts audits of billings and claim payments of providers. The Medical Audit Unit of Quality Assurance takes a statistically valid sample of 100 paid waiver claims to test for compliance with applicable regulation, policy and contract language. They examine supporting documentation, including: time sheets; service orders, activity sheets; Plans of Care and other business records. Special audits can be initiated if increased financial volume indicates a potential problem or if complaints have been received regarding a specific provider. Access Agencies are required to obtain independent financial audits annually. These reports are reviewed by the Office of Quality Assurance and any identified weaknesses are addressed. In addition, the State Auditors of Public Accounts conduct audits of the Department's audit process in compliance with the Federal Single Audit Act Amendments of 1996 and the Federal Office of Management and Budget Circular A-133. The Department's Provider Relations Unit monitors provider enrollment to assure that HP Enterprises, fiscal intermediary, is collecting and verifying required provider documentation prior to enrolling participating providers. These onsite audits are conducted every six months.</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 claims that are coded and paid for in accordance with the reimbursement methodology specified in the waiver. Numerator= number of claims paid in accordance with waiver reimbursement strategy Denominator= total number of claims paid</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" 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">HP Enterprises</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" checked="checked" 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" 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" disabled="disabled" 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" 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" disabled="disabled" readonly="readonly"></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" checked="checked" 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" 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> <tr ><td > <div style="padding-bottom: 1.5em; width:90%;" > <span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:pmName" class="inputTextPct">The number and percent of claims reviewed by the Department's Office of Quality Assurance staff that are supported in the provider agency's documentation/records. Numerator= Total number of claims reviewed by QA department that are sup[ported by documentation Denominator= total number of claims reviewed</span> </div> </div> <table id="svapdxIQ_1:dtPMPrntFA: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:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Record reviews, on-site</span><div id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct">Paid claims data is also a data source</span></div></div></div><table id="svapdxIQ_1:dtPMPrntFA: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:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsSaPct" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA: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:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxIQ_1:dtPMPrntFA: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:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="inputTextarea" readonly="readonly">provider agencies</textarea></span></div></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxIQ_1:dtPMPrntFA: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:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsFdCo" checked="checked" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsSaOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="inputTextarea" readonly="readonly">statistically valid sample of 100 paid waiver claims</textarea></span></div></div></div></span></td> </tr> <tr> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA: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:dtPMPrntFA: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:dtPMPrntFA:1:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxIQ_1:dtPMPrntFA: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:dtPMPrntFA:1:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:pmDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:pmDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:pmDaFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:pmDaRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:pmDaRpOthDsc" name="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:pmDaRpOthDsc" class="inputTextarea" readonly="readonly">contracted entity</textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:pmDaFdAn" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA: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:dtPMPrntFA:1:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:pmDaFdCo" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA: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:dtPMPrntFA:1:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:pmDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxIQ_1:dtPMPrntFA:1:svQmPerfMeas:pmDaFdOtDsc" name="svapdxIQ_1:dtPMPrntFA: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="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:pmNameLabel" class="outputText">Performance Measure:</span> <div> <span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:pmName" class="inputTextPct">Number and percent of waiver claims that are denied due to existing system edits and audits. Numerator= total number of claims denied Denominator= total number of claims</span> </div> </div> <table id="svapdxIQ_1:dtPMPrntFA: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="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsTypeLbl" for="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsType"> <span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt1" class="outputText">Data Source</span><span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsTypeLabeltxt2" class="outputTextNB"> (Select one):</span></label><div id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsTypeDDDiv"><span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsType" class="inputText">Other</span><div id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsOtherNamelblDiv"><label id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsNameLbl" for="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsName"> <span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsNameLabeltxt" class="outputTextNB">If 'Other' is selected, specify:</span></label><div id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:panel_dsName"><span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsName" class="inputTextPct">Claims data reports generated by MMIS vendor</span></div></div></div><table id="svapdxIQ_1:dtPMPrntFA: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="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:txtDSrp" class="outputText">Responsible Party for data collection/generation</span><span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:txtDSrp2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:txtDSfom" class="outputText">Frequency of data collection/generation</span><span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:txtDSfom2" class="outputTextNB em">(check each that applies):</span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:txtDSsa" class="outputText">Sampling Approach</span><span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:txtDSsa2" class="outputTextNB em">(check each that applies):</span></td> </tr> <tr> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsrp1"><div id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:PMrp1div" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsRpSma" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:lbl_dsRpSma" for="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsRpSma" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpSma" class="outputText">State Medicaid Agency</span></label></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsfom1"><div id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsFdWkdiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsFdWk" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:lbl_dsFdWk" for="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsFdWk" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdWk" class="outputText">Weekly</span></label></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dssa1"><div id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsSaPctdiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsSaPct" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsSaPct" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:lbl_dsSaPct" for="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsSaPct" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaPct" class="outputText">100% Review</span></label></div></span></td> </tr> <tr> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsrp2"><div id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsRpOpadiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsRpOpa" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:lbl_dsRpOpa" for="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsRpOpa" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOpa" class="outputText">Operating Agency</span></label></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsfom2"><div id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsFdModiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsFdMo" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:lbl_dsFdMo" for="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsFdMo" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdMo" class="outputText">Monthly</span></label></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dssa2"><div id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsSaLtPctdiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsSaLtPct" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:lbl_dsSaLtPct" for="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsSaLtPct" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:2: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:2:svQmPerfMeas:dtDataSource:0:dsrp3"><div id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsRpCmadiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsRpCma" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:lbl_dsRpCma" for="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsRpCma" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpCma" class="outputText">Sub-State Entity</span></label></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsfom3"><div id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsFdQudiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsFdQu" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:lbl_dsFdQu" for="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsFdQu" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdQu" class="outputText">Quarterly</span></label></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dssa3" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsSaRsdiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsSaRs" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsSaRs" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:lbl_dsSaRs" for="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsSaRs" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaRs" class="outputText">Representative Sample</span></label></div><div id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsSaRsOuterDiv" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsSaRsDsclbldiv" class="firstIndent"><label id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:lbl2_dsSaRsDsc" for="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaRsDsc" class="outputTextNB">Confidence Interval =</span></label></div><div id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:div_dsSaRsDscOuter" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:div_dsSaRsDsc" class="inputTextareaWA"><span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:panel_dsSaRsDsc"><textarea id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsSaRsDsc" name="svapdxIQ_1:dtPMPrntFA: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="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsrp4"><div id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsRpOthdiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsRpOth" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:lbl_dsRpOth" for="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsRpOth" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsRpOth" class="outputText">Other</span></label></div><div id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsRpOthDsclbldiv" class="firstIndent"><label id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:lbl2_dsRpOthDsc" for="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:txtlbl2_dsRpOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:divouterdsRpOthDsc" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:div_dsRpOthDsc" class="inputTextareaWA"><span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:panel_dsRpOthDsc"><textarea id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" name="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsRpOthDsc" class="inputTextarea" readonly="readonly">contracted entity</textarea></span></div></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsfom4"><div id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsFdAndiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsFdAn" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:lbl_dsFdAn" for="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsFdAn" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsFdAn" class="outputText">Annually</span></label></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dssa4" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsSaStrdiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsSaStr" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsSaStr" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:lbl_dsSaStr" for="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsSaStr" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaStr" class="outputText">Stratified</span></label></div><div id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsSaStrOuterDiv" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsSaStrDsclbldiv" class="firstIndent"><label id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:lbl2_dsSaStrDsc" for="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:txtlbl2_dsSaStrDsc" class="outputTextNB">Describe Group:</span></label></div><div id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:divOuterdsSaStrDsc" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:div_dsSaStrDsc" class="inputTextareaWA"><span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:panel_dsSaStrDsc"><textarea id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsSaStrDsc" name="svapdxIQ_1:dtPMPrntFA: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="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsrp5"></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsfom5"><div id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsFdCodiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsFdCo" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsFdCo" checked="checked" class="selectBooleanCheckbox" onclick="" disabled="disabled" /><label id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:lbl_dsFdCo" for="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsFdCo" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:txtlbldsFdCo" class="outputText">Continuously and Ongoing</span></label></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dssa5" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsSaOthdiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsSaOth" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsSaOth" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:lbl_dsSaOth" for="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsSaOth" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:txtlbl_dsSaOth" class="outputText">Other</span></label></div><div id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsSaOthOuterDiv" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsSaOthDsclbldiv" class="firstIndent"><label id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:lbl2_dsSaOthDsc" for="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:txtlbl2dsSaOthDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:divOuterdsSaOthDsc" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:div_dsSaOthDsc" class="inputTextareaWA"><span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:panel_dsSaOthDsc"><textarea id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsSaOthDsc" name="svapdxIQ_1:dtPMPrntFA: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="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsrp6"></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsfom6"><div id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsFdOtdiv" class="checkboxGroup"><input id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsFdOt" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:lbl_dsFdOt" for="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsFdOt" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:txtlbldsFdOt" class="outputText">Other</span></label></div><div id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsFdOtDsclbldiv" class="firstIndent"><label id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:lbl2_dsFdOtDsc" for="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:txtlbl2dsFdOtDsc" class="outputTextNB">Specify:</span></label></div><div id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:divOuterdsFdOtDsc" class="firstIndent"><div id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:div_dsFdOtDsc" class="inputTextareaWA"><span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:panel_dsFdOtDsc"><textarea id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" name="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:dtDataSource:0:dsFdOtDsc" class="inputTextarea" disabled="disabled" readonly="readonly"></textarea></span></div></div></span></td> <td class="third"><span id="svapdxIQ_1:dtPMPrntFA: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="svapdxIQ_1:dtPMPrntFA: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="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:txtPMrp" class="outputText">Responsible Party for data aggregation and analysis </span><span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:txtPMrp2" class="outputTextNB em">(check each that applies):</span> </th> <th id="fom" class="third"> <span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:txtPMfom" class="outputText">Frequency of data aggregation and analysis</span><span id="svapdxIQ_1:dtPMPrntFA: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="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:pmDaRpSma" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:pmDaRpSma" checked="checked" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:lbl_pmDaRpSma" for="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:pmDaRpSma" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:txtlbl_pmDaRpSma" class="outputText">State Medicaid Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:pmDaFdWk" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:pmDaFdWk" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:lbl_pmDaFdWk" for="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:pmDaFdWk" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:txtlbl_pmDaFdWk" class="outputText">Weekly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:pmDaRpOpa" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:pmDaRpOpa" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:lbl_pmDaRpOpa" for="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:pmDaRpOpa" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:txtlbl_pmDaRpOpa" class="outputText">Operating Agency</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:pmDaFdMo" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:pmDaFdMo" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:lbl_pmDaFdMo" for="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:pmDaFdMo" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:txtlbl_pmDaFdMo" class="outputText">Monthly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:pmDaRpCma" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:pmDaRpCma" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:lbl_pmDaRpCma" for="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:pmDaRpCma" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:txtlbl_pmDaRpCma" class="outputText">Sub-State Entity</span></label> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:pmDaFdQu" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:pmDaFdQu" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:lbl_PMsiFomQu" for="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:pmDaFdQu" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:txtlbl_pmDaFdQu" class="outputText">Quarterly</span></label> </div> </td> </tr> <tr> <td headers="rp"> <div class="checkboxGroup"> <input id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:pmDaRpOth" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:pmDaRpOth" checked="checked" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:lbl_pmDaRpOth" for="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:pmDaRpOth" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:txtlbl_pmDaRpOth" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:lbl2_pmDaRpOthDsc" for="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:pmDaRpOthDsc" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:txtlbl2_pmDaRpOthDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:panel_pmDaRpOthDsc"><textarea id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:pmDaRpOthDsc" name="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:pmDaRpOthDsc" class="inputTextarea" readonly="readonly">contracted entity</textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:pmDaFdAn" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:pmDaFdAn" class="selectBooleanCheckbox" disabled="disabled" readonly="readonly" /><label id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:lbl_pmDaFdAn" for="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:pmDaFdAn" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA: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="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:pmDaFdCo" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:pmDaFdCo" checked="checked" class="selectBooleanCheckbox" disabled="disabled" /><label id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:lbl_pmDaFdCo" for="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:pmDaFdCo" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA: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="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:pmDaFdOt" type="checkbox" name="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:pmDaFdOt" class="selectBooleanCheckbox" onclick="return callSave(this, event);" disabled="disabled" /><label id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:lbl_pmDaFdOt" for="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:pmDaFdOt" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:txtlblpmDaFdOt" class="outputText">Other</span></label> </div> <div class="firstIndent"> <label id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:lbl2_pmDaFdOtDsc" for="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:pmDaFdOtDsc" class="outputLabel"> <span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:txtlblpmDaFdOtDsc" class="outputTextNB">Specify:</span></label> </div> <div class="firstIndent"> <div class="inputTextareaWA"> <span id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:panel_pmDaFdOtDsc"><textarea id="svapdxIQ_1:dtPMPrntFA:2:svQmPerfMeas:pmDaFdOtDsc" name="svapdxIQ_1:dtPMPrntFA: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="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">Number and percent of rates that are reviewed annually for compliance with the methodology in the approved waiver. Numerator= number of rates reviewed annually Denominator= 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">Reports developed by Medicaid rate setting unit</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" 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> </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">The Access Agencies and the state's fiscal intermediary are contractually responsible for monitoring the performance of the subcontractors. The fiscal intermediary must verify that each direct service provider meets the eligibility criteria to be a waiver provider. The Access Agency must also evaluate the quality of services provided to waiver recipients. They are responsible for the oversight of the subcontractors performing services for waiver participants. The fiscal intermediary monitors direct service provider eligibility and adherence to program requirements and standards while the Access Agencies moniotor the quality of service and service delivery in accordance with clients' plans of care. The fiscal intermediary is also required to do a sample of onsite provider reviews to assess for the adequacy of documentation that would support the billing for the service. All providers are limited to billing approved procedure codes from the waiver fee schedule at the established rate. The Interchange system is coded with edits and audits that prohibit claim payment to non-waiver providers. Clients are assigned to a care management agency. All providers must be directly enrolled as CT Home Care Program for Elders provider type/specialty and bill from the allowed set of procedure codes. The Access Agency will load the authorized service plan into a web portal and the provider agencies will bill against the authorized plan. Services that are billed that were not authorized will deny payment.</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">Billing irregularities are analyzed and necessary action is taken to correct the problem. Additional training may be provided if needed either by the fiscal intermediary or HP Enterprises or both. Money may be recouped and legal action taken, if fraudulent claim activity is suspected and/or substantiated. The billing providers receive a remittance advice from HP Enterprises indicating all claims submitted, claim status (paid, denied, suspended, recoupment, mass adjustment). The remittance advice shows amount allowed, amount paid, client applied income deducted. Denied claims use a four digit code to denote denial reason. The code key appears on the remittance advice. There are two basic categories of denial reasons for the waiver - eligibility errors and provider errors. The Medicaid waiver program requires that key fields are entered correctly in the Eligibility Management System (EMS). An error or omission can cause claim denial. Providers bring these claims to DSS' attention for remediation. Medicaid clients are often granted Medicaid retroactively. Claims submitted prior to the date the client is granted eligibility will deny. Providers can bill retroactively up to one year from the date the client was granted the Medicaid waiver. DSS works with the provider agencies to let them know when retroactive eligibility has occurred. Claims can be submitted on paper claim forms - the CMS 1500 (V08-5), the UB-04 or electronically. All provider are encouraged to submit electronically. HP Enterprises provider relations unit is available to help providers by phone, through formal training sessions that are held quarterly, or by onsite visits to help providers who need extra assistance with their claim submissions. HP Enterprises has a dedicated EDI Help Desk for providers experiencing difficulties with electronic claim submissions. All provider interaction with HP Enterprises is documented through the Contact Tracking Management System (CTMS) which logs the date, provider, reason for the call and resolution of the problem.</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" checked="checked" 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">contracted entity</textarea></span> </div> </div> </td> <td headers="fom"> <div class="checkboxGroup"> <input id="svapdxIQ_1:qmFaDaFdAn" type="checkbox" name="svapdxIQ_1:qmFaDaFdAn" checked="checked" 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" checked="checked" 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" 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"></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">Rates are determined by the Department's Rate Setting Unit. Pursuant to the Connecticut Department of Social Services Provider Manual, all schedules of payment for covered Medical Assistance Program goods and services shall be established by the Commissioner of Social Services and paid by the Department of Social Services in accordance with applicable federal and state statutes and regulations. Waiver service rates are based on direct and indirect costs of providing Waiver services. Consumers, provider organizations and DSS staff have had the opportunity to review the Waiver application and rates pursuant to the public notice. The Waiver application has been reviewed and approved by the committees of cognizance of the Connecticut state legislature. The rate structure for the program consists of 1) fee-for-service billing from an established fee schedule that pays uniform rates across providers; 2) usual and customary rates established individually with providers based on special provider needs such as serving hazardous urban areas which require accompaniment by security personnel; 3)"up to max" rates that are used for assistive technology equipment or other services such as home modifications that require manual pricing. Maximum allowable rate for services are established by the department in its fee schedule. Rates do not vary for different providers of waiver services. Rates are usually prospective. If retroactive rate setting should occur, this will result in mass adjustments during a claim cycle to either compensate providers for a rate increase or recoupments if rates are decreased. During the life of this waiver, service rates may be adjusted based on legislatively approved increases or decreases to the Department's appropriation. The following services are priced as usual and customary: Skilled nursing services - Nursing care in the home by RN S9123, RN service S9123, T1002; Nursing care in the home by LPN S9124; LPN/LVN services S9124, T1003; Nursing Assessment Evaluation T1001; RN Services, Assessment T1001, T1002; Services of a qualified nurses aide T1004; Physical therapy S9131, Occupational therapy S9129; Speech therapy S9128; Administration of medication other than oral and/or injectable by health care agency/professional T1503; Administration of medication by a health care professional T1502. The following services are priced at max fee - Adult Day Health Full Day Medical Model, Adult Day Health non-Medical model, Adult Day Health half day, Adult Family Living/Foster Care, Meals on Wheels -single, double, kosher/ethnic; homemaker, companion, choreperson, personal care attendant agency, personal care attendant individual, mental health counseling - office or home visit; emergency response system installation, one way, two way ongoing; laundry service, respite care by companion, homemaker, nurses aide, rest home with nursing supervision, chronic care facility with nursing supervision, home for the aged per day, in home/out of home other; social transportation - taxi, livery, invalid coach; case management, status review - hospital, nursing facility, home; initial assessment, reasssessment, self directed care claim processing fee. The following are manually priced: Highly skilled chore service and minor home modifications. The following is priced up to max: Assistive Technology. 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. Waiver participants are provided with rate information by the care manager during the development of the total plan of care. 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 base rate established previously in an earlier version of this waiver. There were add-ons at each level of the service based on the individual participants assessed cognitive, functional and behavioral needs. 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 department issued an RFP in December of 2012 to procure care management services. Contracts were awarded in June of 2013. The rate methodology for care management was cost-based, determined by the budgets submitted by each Access Agency in response to the RFP. The maximum allowable rate for the per diem care management service was lowered as a result of the unbundling and reassigning of the fiscal intermediary functions to a currently contracted fiscal intermediary. 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 rate for Care Transitions is calculated at one-half the cost of the assessment based on budget information, care manager costs and time estimates for the provision of this service. The Chronic Disease Self Management Program is a national program that has been utilized in the state as a grant funded program. The rate is based on the national average (NCOA cost calculator) and the rate used in the state when the program was grant funded. The rate for the Bill Payer service was based on the rate for Homemaker with a bump up based on additional bonding requirements and a skill set beyond that of the Homemaker.</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">The Department has engaged with its MMIS provider HP to develop a web-based claims portal where the Access Agency enters the authorized service plan into the portal and the providers bill claims through the portal. Claims are checked against the service plan authorized by the care manager. Services that were not authorized will deny. Instead of the providers subcontracting with the Access Agencies, all waiver providers are now enrolling directly with the Department through an enrollment wizard in the HP system. One statewide fiscal intermediary will perform all credentialing functions and providers will be unable to enroll without producing the credentialing document. This direct relationship between waiver providers and the department will enable improved communication and monitoring of providers' performance. The care plan portal will allow only authorized services to pay ensuring compliance with the plan of care. HP will be producing reports that will compare authorized services to actual paid claims so that areas or providers needing follow up can be identified. This also allows for trending analysis of utilization patterns. Problematic agencies are identified and remediation plans are initiated. The Access Agency bills for the case management services and assessment services the Access Agency provides. Claims are submitted to HP Enterprise Services (formerly EDS) which operates the Department's MMIS system. Allied Community Services is the fiscal intermediary who bills HP Enterprise Services (EDS) directly for personal care attendant. Home Health Agencies and Assisted Living Service Agencies may also bill the MMIS system (HP Enterprises) directly.</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 will be made to the Medicaid program directly to providers of Waivers and State Plan services with the exception of payments to the fiscal intermediary for Waiver Services that are not Extended State Plan Services. There will be provider agreements between DSS and each State Plan Services provider of services and between DSS and the Fiscal Intermediary under the Waiver. Payments for all Waiver and State Plan services will be made through the same fiscal agent as used in the rest of the Medicaid program. The fiscal intermediary reviews the authorized service plan and edits in their billing systems do not allow them to process the claims and submit to the MMIS for payment unless the service was authorized by the care manager. Providers are required to obtain client signature for services and this is reviewed upon audit by the Access Agencies and by DSS Division of Quality Assurance. The MMIS, Interchange, interfaces with the DSS Eligibility Management System (EMS) to validate client eligibility to assure that claims are paid only for eligible clients. Interchange assigns clients to a benefit plan. The benefit plan provides eligibility parameters for both the clients and for what services the providers can bill. For example, companion is not a Medicaid state plan covered service. The Benefit Plan "CT Home Care Program for Elders (CHCPE)" would allow that claim with the procedure code for companion to pay. Another example of a Benefit Plan is Assisted Living. The procedure code for home modifications is not a payable procedure code for Assisted Living Providers, the claim will deny if presented to HP Enterprises for processing because the procedure code for home modifications is not part of the Assisted Living benefit plan. It is the responsibility of the care manager/Access Agency to design a plan of care in conjunction with the client and significant others, to prevent client care plans from exceeding cost caps and to ensure that designated services are actually being provided. Proof of service delivery can be detected upon audit by DSS Quality Assurance.</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" 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" 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" checked="checked" 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">(a)The state issued a new RFP for this waiver for care management providers and the new contracts became effective 7/1/13. In the new contract, performance incentives were added to reward quality outcomes for waiver participants. It is the goal of the Department to improve the experience for waiver participants, improve participant outcomes, improve access to care, ensure participants have choice and control, ensure that participants are treated respectfully and their dignity is maintained and that participants have opportunities for community integration and/or inclusion. The payments will be made as an adjustment to the case management rate for each provider that qualifies for the incentive. Performance Incentive Standards are as follows in year one and each subsequent year of the Contract: 1) Maintaining or improving the baseline level of client satisfaction that will be the Client satisfaction survey results for SFY 13: July 01, 2012-June 30, 2013 2) Longest average length of stay on the waiver. In addition to the Participant Experience Survey (PES), the state will use client satisfaction surveys and data from the waiver database to determine the agency with the longest length of stay for waiver participants. The state has applied for a TEFT grant. If awarded, CMS TA contractors would be administering the PES to a random, representative sample of waiver participants. This fiscal year will serve as the baseline data. On an ongoing basis, the sample will be a stratified, representative sample. If the TEFT grant is awarded, the state intends to utilize the University of Connecticut Center on Aging to administer the surveys. If the state is not awarded the TEFT grant, then surveys will be conducted by Alternate Care Unit staff. All Access Agencies will be eligible for all of the incentive payments. The baseline data from the Participant Experience Survey will enable the state to determine the baseline for each of the measures. Each provider is eligible for an incentive payment for each of the six performance measures. For example, an agency may receive an incentive for the longest length of stay but be below the baseline on two of the four measures from the PES, therefore they would qualify for three of the six performance incentives. The following four Performance Incentives will be in accordance with the CMS Participant Experience Survey. The Incentives will be awarded evidenced on participant responses to the survey based on a random, representative sample of active program participants. The measures will be established on clients responses to questions that will be related to the following: 1) Access to care; 2) Having choice and control over the assistance received; 3) Being treated with respect and dignity; and 4) Being included in the Community. The purpose of the PES is as follows: The purpose of the PES E/D is to provide State officials with information about program participants&#8217; experience with the services and supports they receive under the 1915(c) waiver program &#8212; the Medicaid Home and Community Based Services waivers. &#9679; The PES E/D is a technical assistance tool that States may consider using as part of their quality management program to monitor quality in their waiver programs. &#9679; Target population is elderly and non-elderly adults with physical disabilities. &#9679; The PES provides indicators of program participants&#8217; experience in four priority areas: &#9632; Access to Care: Are program participants&#8217; needs for personal assistance, adaptive equipment, and case manager access being met? &#9632; Choice and Control: Do program participants have input into the types of services they receive and who provides them? &#9632; Respect/Dignity: Are program participants treated with respect by providers? &#9632; Community Integration/Inclusion: Do program participants participate in activities and events of their choice outside their homes when they want to? &#9679; The PES E/D can be used to calculate 33 performance indicators, within these priority areas, for quality monitoring and intervention. These indicators can be calculated for the entire sample, or for different sub-samples, such as program participants residing in different counties or served by different providers, and compared across groups. The performance incentive payments will be made to the providers of care management services only as part of the daily care management rate The state's share of the performance incentive payments will come from the General Fund The care management providers will retain 100% of the total computable expenditure</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 inp