Scope of Work and Rate Table.pdf

ATTACHMENT A

SCOPE OF WORK

A. General Description

To provide installation and monitoring of personal emergency response systems

(“PERS”) and automatic medication dispensary devices (“MDD”).

B. Definitions

In this contract, the following definitions apply:

“Emergency Response Center” means the location where Staff provide services related to PERS, including monitoring, and responding to signals received from PERS.

“Home Based” means the PERS has a limited range and may not work outside of the

Person’s home.

“MDD” means an automatic device that stores, dispenses, and tracks medication.

“Mobile Home and Away” means the PERS can be used at the Person’s home, in the community, and while traveling.

“PERS” means a two-way communication system that allows a Person to call for help and receive assistance in an emergency by pushing a button/pendant.

“Person” means:

1. An individual who has intellectual disabilities, related conditions, or acquired brain injury (“ID.RC.ABI”) as defined in Utah Administrative

Code, Rule R539-1 and found eligible to receive services by the Utah

Department of Human Services (“DHS”), Division of Services for People with Disabilities(“DSPD”), or

2. An individual who is a DHS Client.

“Staff” means the Contractor or any of its employees providing or coordinating services for the Person, including installing PERS, delivering MDDs, and providing assistance to

Persons from the Emergency Response Center.

C. Population Served

The Contractor shall provide the services specified herein to Persons receiving services through DHS.

D. Contractor Qualifications

The Contractor shall:

1. Be approved as a Medicaid provider for the community support waiver, acquired brain Injury waiver, and the physical disabilities waiver with the Utah Department of Health, Division of Medicaid and Health Financing. This approval process will be administered by the DSPD Medicaid Enrollment Manager. The Contractor shall complete and provide all required documentation as directed by the DSPD

Medicaid Enrollment Manager;

2. Maintain an active registration with the Utah Department of Commerce, Division of Corporations and Commercial Code;

3. Have a current Grant of Equipment Authorization by the Federal Communications

Commission (“FCC”) or a statement explaining why a Grant of Equipment

Authorization is not required; and

4. Have a current and active DSPD USTEPS Provider Interface (“UPI”) account, comply with UPI requirements pursuant to this contract, and comply with electronic access and process changes as they develop. UPI access forms are available on the DSPD web page: dspd.utah.gov.

E. Staff Qualifications

The Contractor shall ensure its Emergency Response Center Staff is trained to provide emergency service protocols with Persons in Home and Community Based Services

Waiver programs.

F. Training Requirements

The Contractor shall participate in any required Utah Department of Health or DSPD training.

G. Administrative Requirements

1. Be in compliance with the UPI use including:

a. Have a current active user account with UPI. UPI access forms can be found on the DSPD web page: dspd.utah.gov;

b. Complete the DSPD form “0-9 USTEPS Provider Interface (UPI) Provider

Company Designee Access Form”; and

c. Complete the DSPD form “0-8 USTEPS Provider Interface (UPI)

Individual User Access Form” for at least one Staff.

2. Ensure that access to UPI is only granted to Staff who need to know the information in UPI to provide equipment or coordinate DSPD services.

3. Ensure each Staff member with UPI access is trained in HIPAA privacy requirements.

4. Approve or reject the approved DSPD Purchase Service Authorization Form 1056

(“1056”) through UPI within 15 business days of the creation of a new or adjusted

1056. If the Contractor rejects the 1056, the Contractor must coordinate with the

Person’s support coordinator to either adjust the 1056 or transition the service to a different Contractor.

5. Use the UPI “Provider Organization” section to create and maintain a Contractor organizational group structure that will restrict UPI users from seeing a Person’s information that is not required to provide equipment or coordinate DSPD services.

6. Assign and maintain Staff with UPI access to the appropriate organizational group(s).

7. Assign and maintain email addresses and notification preferences for each employee with UPI access.

8. Assign and maintain each Person to the appropriate organizational group(s).

9. Remove terminated Staff from the “Provider Organization” within one business day of termination.

10. Remove Staff from an organizational group within one business day of the employee no longer having a need to know the information in UPI to provide equipment or coordinate DSPD services.

11. Remove a Person to whom Contractor is no longer providing services from the

“Provider Organization” section within one business day.

12. Ensure that each Staff person providing services under this contract reads and reviews annually the DHS Provider Code of Conduct and the DSPD Code of

Conduct and that each Staff person signs and dates a statement certifying that each code of conduct has been read and understood, and ensures compliance.

H. General Service Requirements

1. Sell or lease PERS or MDD equipment and monitoring services;

2. Have customer service Staff trained in using the Contractor's devices who can promptly respond to the Person’s questions within 24 hours;

3. Provide services only after receiving a DSPD 1056 through UPI;

4. Contact the Person and schedule a time for installation of PERS or MDD;

5. Prior to the scheduled installation of PERS or MDD, obtain a contact list of at least three names and phone numbers of people that the Contractor will use for notification during an emergency. The list must be validated and updated, as needed, and at least annually;

6. Ensure during installation of PERS or MDD:

a. At least one individual from the Person’s contact list is present; and

b. Train the Person and the individual from the Person’s contact list on how to properly set-up, test the device, and provide them with a user’s manual.

c. If the Person is under 18 years of age or has a guardian, train the Person’s parents, guardians, or the Person’s residential provider staff and provide them with a user’s manual;

7. Provide maintenance on PERS and MDD which includes the following:

a. Ensure that each device is operational at all times;

b. Test and monitor each device on a monthly basis. This must include a test of the battery status; and

c. Repair each device to full operational condition, replace, or provide loaner equipment within 48 hours of receiving notice that the device is not functioning properly.

I. Specific Service Requirements for PERS

PERS must be electronic communication equipment which electronically signals an

Emergency Response Center for help when activated by the Person. The Person will use a button/pendant to activate the signal to the Emergency Response Center. The

Contractor shall ensure:

1. The button/pendant used with the PERS is:

a. Water resistant; and

b. Can be easily activated by Persons with severe and significant disabilities.

2. At the time of the installation, the Staff shall physically call to test the device for transmitter range and voice range.

3. Continuous monitoring of PERS signals: When the button/pendant is activated, the Person must be connected with the Contractor’s Emergency Response Center

Staff. The Staff shall:

a. Respond within 30 seconds by contacting the Person on the two-way communication;

b. Identify the emergency and clarify the Person’s need; and

c. Provide assistance consistent with each Person's safety needs and disabilities. This includes calling the Person’s emergency contacts on the

Person’s contact list in the order indicated by the Person;

4. Home Based landline and cellular PERS include:

a. An in-home two-way telecommunications system that includes a transmission device and button/pendant that is worn by the Person at all times;

b. A button/pendant which must function within the stated range of

Contractor’s system;

c. A self-charging backup battery that allows the Contractor to monitor and respond to Persons at all times including during a power outage;

d. A two-way voice speaker home unit; and

e. Security and emergency response services for each Person wearing the button/pendant which must connect to the in-home telecommunications system.

5. If multiple Persons live in the same home, the Persons will share the Home Based

PERS transmission system. Each Person sharing the transmission system must be issued their own button/pendant;

6. If using Mobile Home and Away PERS:

a. The Person’s privacy must be respected. The PERS device must not be a tracking device. The location of the Person must only be used to provide assistance to the Person when the Person activates the button/pendant;

b. The PERS must have a battery life of at least 24 hours;

c. The PERS must have a two-way communication system that allows for the

Contractor and the Person to communicate with each other through the

PERS; and

d. The battery charge must be monitored by the Contractor and the Person must be notified when is the battery charge is low;

7. At the conclusion of each call, the Contractor shall send the Person’s support coordinator an e-mail notice of each emergency call processed. The e-mail must include:

a. The name of the Person assigned to the emergency response button;

b. The time the emergency response button was pushed;

c. The type of emergency;

d. Who was contacted to help with the emergency; and

e. The resolution of the emergency.

J. Specific Service Requirements for MDD

1. Provide the Person with a MDD that has the following functions:

a. A timed alarm system to remind the Person to use the MDD;

b. Notification to the Contractor to activate support protocol for missed medication resulting from the Person not accessing the MDD;

c. The ability to store, track, and automatically dispense the proper dosage of medication to Persons at a scheduled time, one to four times daily, as prescribed by the Person’s physician;

d. If a Person does not take their medication from the MDD within the

Person’s required time protocol, as set up by the individual filling the

MDD; the system notifies the Contractor's Emergency Response Center within 15 minutes to one hour;

2. Contact the Person within five minutes when the Emergency Response Center is notified that a Person did not take their medication from the MDD to ensure the medication is taken. If the Person cannot be reached, or cannot take the medication, the Contractor shall immediately contact the proper individuals indicated in the Person’s contact list.

3. Not fill the MDD. It is the Person’s responsibility to have the MDD filled by the

Person’s pharmacy, family, or qualified residential provider staff.

K. Limitations

1. Not require a Person enrolled in PERS to also enroll in the MDD service or vice versa;

2. Not require roommates or others living in the home with the Person to use the

Contractor’s services; and

3. Not require Persons to be responsible for equipment if it is lost or destroyed.

Rate Table

Description Service

Code Rate Unit Limitations

Installation of PERS, MDD or both PERS and MMD (required)

PEI $35.06 Need One-Time Expense

PERS Home Based - purchase PEP $200.00 Need One-time Expense

MDD purchase PE1 $310.00 Need One-time Expense

Replacement of lost button/pendants for

Home Based- landline or Home Based-cellular PERS

PEQ $30.05 Need Replacement of lost button/pendants

Replacement of lost Mobile Home and Away

PERS

PMQ $150.00 Need Replacement of lost Mobile Home and Away PERS

MONITORING FEE FOR LEASED EQUIPMENT

PERS Home Based - landline without fall detection

PER $27.00 Monthly With leased equipment

PERS Home Based – cellular without fall detection

PEC $35.00 Monthly With leased equipment

PERS Home Based-landline or Home Based

– cellular with fall detection

PEF $38.00 Monthly With leased equipment

PERS Mobile Home and Away with or without fall detection

PEM $38.00 Monthly With leased equipment

MDD PE2 $42.00 Monthly With leased equipment

Additional Persons monitored through the same Home Based transmission system

PES $5.00 Monthly Monitoring each additional Person in a home that uses a PERS

MONITORING FEE FOR PURHASED EQUIPMENT

MDD PE4 $21.00 Monthly With purchased equipment

Additional Persons monitored through the same Home Based transmission system

PES $5.00 Monthly Monitoring each additional Person in a home that uses a PERS

PERS Home Based with or without fall detection or Mobile Home and Away with or without fall detection

PEO $15.00 Monthly With purchased equipment.