D.C. Mun. Regs. tit. 29, § 9019
9019.1 The purpose of this section is to establish standards governing Medicaid eligibility for day habilitation for persons enrolled in the IFS Waiver, and to establish conditions of participation for providers of day habilitation services.
9019.2 Day habilitation services are aimed at developing meaningful adult activities and skills acquisition to: support or further community integration, inclusion, and exploration, improve communication skills; improve or maintain physical, occupational or speech and language functional skills; foster independence, self-determination and self-advocacy and autonomy; support persons to build and maintain relationships; facilitate the exploration of employment or integrated retirement opportunities; help a person achieve valued social roles; and to foster and encourage persons on their pathway to community integration, employment and the development of a full life in the person's community.
9019.3 Day habilitation services are intended to be different and separate from residential services. These services are delivered in group settings or can be provided as day habilitation one-to-one services.
9019.4 Medicaid reimbursable day habilitation services may also be delivered in small group settings at a ratio of 1:3 for persons who are medically or behaviorally complex, as verified by the DDA LON Assessment and Screening Tool, or its successor tool, or the person's BSP, and who would benefit from day habilitation services in a smaller setting. Small group day habilitation settings must include integrated skills building in the community and support access to the greater community. In order to be Medicaid reimbursable, small group day habilitation:
9019.5 To be eligible for day habilitation services:
(b) A person shall have a demonstrated personal or social adjustment need that can be addressed through participation in a habilitation program that is individualized to meet their goals, preferences, and needs.
9019.6 Day habilitation one-to-one services shall consist of:
9019.7 To be eligible for day habilitation one-to-one services, a person shall meet at least one of the following requirements:
9019.8 Day habilitation one-to-one services shall be authorized and approved in accordance with DDS/DDA policies and procedures available at http://dds.dc.gov/page/policies-and-procedures-dda.
9019.9 Day habilitation services shall be provided pursuant to the following service delivery criteria:
(c) The service shall be provided in the most integrated setting appropriate to the needs of the person.
9019.10 In order to be reimbursed by Medicaid, day habilitation services shall consist of the following age-appropriate learning or habilitative activities that are based on what is important to and for the person as documented in his or her Individualized Support Plan and reflected in his or her Person-Centered Thinking and Discovery tools:
integration and inclusion activities at least once per week, and more if indicated by the ISP;
(5) DDS recommends the use of learning logs for documentation of community integration and inclusion activities;
(6) At least quarterly, there must be a community integration activity for each person in which a Day Habilitation Program Coordinator, Assistant Director, or a Qualified Intellectual and Developmental Disabilities Professional participates to ensure: proper matching of participants; that the community outings reflect each person's interests, goals, or friendships; that each person receiving supports has opportunities to engage with people while in the community and to coach DSPs on the skills needed to successfully connect persons receiving supports with the broader community, progress being made and this must be fully documented in the quarterly report; and
(7) Each day habilitation provider must have, and must train their DSP staff on, written protocols regarding how DSPs are expected to support persons in the community and requirements for documenting progress notes regarding community engagement activities; and
(g) Individualized or group services that enable the person to attain his/her maximum functional level based on the ISP and Plan of Care.
9019.11 Day habilitation services shall include a Registered Nurse for the purposes of:
9019.12 Day habilitation services shall include a nutritionally adequate meal for participants who live independently or in the family home and who select to receive a meal. The meal shall be provided during lunch hours, meet one-third of a person's daily Recommended Dietary Allowance, be based on the person's preferences, and not be medically contraindicated.
9019.13 Each day habilitation provider shall develop a day habilitation plan for each
person in accordance with the following:
9019.14 Each provider of Medicaid reimbursable day habilitation services shall develop, with the person, an individualized schedule of daily activities that meets all requirements in the DDS guidance on daily schedules, including that it is based upon the person’s goals and activities as identified in his or her ISP, and consistent with what is in his or her Person-Centered Thinking and Discovery tools, of meaningful adult activities that support the person on his or her pathway to employment and community integration and inclusion.
9019.15 Day habilitation providers may not pay a stipend to a person for attendance or participation in activities at the day habilitation program.9019.16 Each day habilitation provider shall meet the following provider qualification and enrollment requirements:- (a) Comply with the requirements described under Section 9010 (Provider Qualifications) and Section 9009 (Provider Enrollment Process) of Chapter 90 of Title 29 DCMR;
- (b) Maintain the required staff-to-person ratio, indicated on the person's ISP and Plan of Care, to a maximum staffing ratio of 1:4 for regular day habilitation or 1:3 for persons in small group day habilitation;
- (c) Shall have at least one individual on staff as a full-time employee or consultant basis that has experience developing adult education programs for a person with intellectual disabilities, to ensure outcome-based learning is taking place; and
- (d) Shall have one individual on staff as a full-time employee or consultant basis that has experience developing adult senior curriculums for persons with intellectual disabilities, to ensure outcome-based learning is taking place.9019.17 In addition to the requirements at § 9019.16, each small group day habilitation provider shall meet the following provider qualifications and enrollment requirements:- (a) Fully comply with all requirements of the HCBS Settings Rule as that phrase is defined in Section 9099 (Definitions); and
- (b) Provide documentation that the program manager of the HCBS Waiver provider agency has at least three (3) years of experience working with persons with intellectual and developmental disabilities who have complex medical or behavioral needs.9019.18 Each DSP providing day habilitation services for a provider shall comply with Section 9011 (Requirements of Direct Support Professionals) of Chapter 90 of Title 29 DCMR.9019.19 To receive Medicaid reimbursement, day habilitation services shall be provided in the community or in a facility-based setting that provides opportunities for community engagement, inclusion and integration. There shall be no increase in the number of facility-based settings authorized for current providers. No facility-
based settings will be authorized for newly enrolling providers, with the exception of small group day habilitation.
9019.20 Each provider of Medicaid reimbursable day habilitation services shall comply with the requirements under Section 9008 (Home and Community-Based Settings Requirements) of Chapter 90 of Title 29 DCMR.
9019.21 All day habilitation services shall be authorized in accordance with the following requirements:
(a) DDS shall provide a written service authorization before the commencement of services;
(b) The day habilitation DSP providing one-to-one services shall be trained in physical management techniques, positive behavioral support practices and other training required to implement the person's health care management plan and behavioral support plan, as applicable;
(c) The service name and provider entity delivering services shall be identified in the ISP and Plan of Care;
(d) The ISP, Plan of Care, and Summary of Supports and Services shall document the amount and frequency of services to be received;
(e) Completion of the person's day habilitation plan;
(f) Approval of the behavioral support plan or the physician's order for one-to-one staffing support for persons receiving day habilitation one-to-one services; and
(g) When required by a person's BSP, accurate completion by the DSP of the behavioral data sheets for persons receiving day habilitation one-to-one services.
9019.22 Each provider shall comply with the requirements described under Section 9013 (Reporting Requirements) and Section 9005 (Individual Rights) of Chapter 90 of Title 29 DCMR. Additionally, quarterly reports shall include a description of the person's activities in the community that support community integration and inclusion using the Person-Centered Thinking Learning Log, available on-line at: https://dds.dc.gov/publication/person-centered-thinking-tools-procedure.
9019.23 Each provider shall comply with the requirements described under Section 9006 (Records and Confidentiality of Information) of Chapter 90 of Title 29 DCMR.
9019.24 There shall be a Medicaid reimbursement rate for regular day habilitation
services. Services shall be provided for a maximum of eight (8) hours per day. The billable unit of service for regular day habilitation services shall be fifteen (15) minutes. A provider shall provide at least eight (8) minutes of service in a span of fifteen (15) continuous minutes to be able to bill a unit of service.
departure and who spend the remainder of their day in the community.
9019.34 Non-small group day habilitation settings established prior to the effective date of these regulations that have a daily census under fifty (50) people may only receive authorizations for services for new participants up to a daily census of fifty (50) people in the setting. Current non-small group day habilitation settings that have a daily census of fifty (50) people or more in the setting will not be eligible for authorizations for services for new participants until their daily census is less than fifty (50) people in the setting.
(a) The daily census includes people who receive support through the IFS Waiver and people who receive ICF/IID supports and are engaged in active treatment at the setting; and
(b) The daily census does not include people who are in the setting only for morning arrival and afternoon departure and who spend the remainder of their day in the community.
9019.35 The following service limitations apply to new enrollees in non-small group day habilitation services:
(a) No new enrollee may attend non-small group day habilitation for more than twenty-four (24) hours per week;
(b) People who are sixty-four (64) years old and younger and have a LON Day Composite score of two (2) or less would not be eligible to attend day habilitation services, unless approved by DDA due to extenuating circumstances or barriers that are expected to be resolved within six (6) months:
(1) This limitation is applicable to small group day habilitation services;
(2) Exceptions may only be granted by DDA for six (6) month periods and must be accompanied by an ISP goal aimed at addressing the barrier to participation in other day or employment Waiver supports; and
(3) Alternative services, including Employment Readiness, Small Group Supported Employment, Individualized Day Supports, and Companion services that are offered during regular day service hours, shall be available, in combination, for up to forty (40) hours per week.
(c) People who are sixty-four (64) years old and younger and have a LON Day
Composite score of three (3) or higher shall not be eligible to attend day habilitation services, unless they already have tried other day and employment options for at least one year:
(1) This limitation is not applicable to small group day habilitation services;
(2) DDS may approve an exception to this prohibition due to extenuating circumstances or barriers that are expected to be resolved within six (6) months. Any exceptions shall be accompanied by an ISP goal aimed at addressing the barrier to participation in other day or employment Waiver supports;
(3) Alternative services including Supported Employment, Individualized Day Supports, Employment Readiness and Companion would be available, in combination, for up to forty (40) hours per week.
9019.36 The following service limitations apply to people who are currently attending non-small group day habilitation services:
(a) Within one (1) year from the Waiver effective date, any person with a LON Day Composite score of one (1) or two (2) shall no longer be eligible for day habilitation services and services may no longer be authorized:
(1) For any person with a LON Day Composite score of one (1) or two (2), the person shall be offered employment services, either through the Waiver, the Rehabilitation Services Administration, or other community-based options;
(2) The transition from day habilitation services shall be implemented on a rolling basis over the course of the year, with the new service limitation discussed and choice of alternative options offered at the person's next ISP meeting, subject to the exception described in subparagraph (3) of this subsection; and
(3) For a person with an ISP meeting that is scheduled within ninety (90) days of the Waiver effective date, DDA may authorize day habilitation services for up to ninety (90) days following the ISP meeting to ensure a smooth transition.
(b) Within one (1) year from the effective date of the Waiver, non-small group day habilitation services may not be authorized for any Waiver participant with a LON Day Composite score above two (2) for more than twenty-four (24) hours per week, subject to the exception described below:
(1) Wrap around services are available, including Supported Employment,
Individualized Day Supports, Employment Readiness and Companion, in combination, for up to forty (40) hours per week;
(2) For people with an ISP meeting that is scheduled within ninety (90) days of the Waiver effective date, DDA may authorize up to forty (40) hours of day habilitation services per week for up to ninety (90) days following the ISP meeting to ensure a smooth transition; and
(3) This limitation is not applicable to small group day habilitation services.
(c) For any person who is currently receiving non-small group day habilitation services who will be subject to a reduction in authorized service hours due to the service limitations identified in these provisions, DDA shall provide timely and adequate due process notice of the change in services and the person’s appeal rights, using the process described in the DDS Person-Centered Planning Process and Individual Support Plans policy and procedures, or the successor documents.
9019.37 Day habilitation services may be delivered through remote supports to the extent the recommended service delivery is through remote supports services and the person is able to utilize equipment/technology needed for remote supports services as assessed and determined by the support team.
9019.38 Each provider of remote day habilitation services shall comply with the requirements under Section 9036 (Remote Supports Services) of Chapter 90 of Title 29 DCMR.
9019.39 Day habilitation, small group day habilitation, and day habilitation 1:1 services delivered through remote supports services shall be provided for a maximum of four (4) hours a day consecutively or in increments, not to exceed twenty (20) hours per week.
9019.40 Remote day habilitation services will be issued as a separate service authorization indicating the frequency of usage. A hybrid model may be used for in-person and remote supports services day habilitation hours where two (2) service authorizations are issued to cover the in-person service hours and the remote supports services hours.
9019.41 Remote day habilitation 1:1, day habilitation and small group day habilitation services staffing ratio are 1:6 and must have active, continuous engagement and contact with the remote support platform. Staff should be available during the service hours and document that they are continuously engaged with the person and/or the remote supports responder platform to bill for hourly services.
9019.42 Day habilitation services provided by HCBS Waiver professionals through remote Public Welfare
supports services must meet the criteria specified at § 9036.12.
SOURCE: Final Rulemaking published at 69 DCR 010229 (August 12, 2022); as amended by Final Rulemaking published at 71 DCR 010475 (August 23, 2024).