1. Reason: Disagreement on service delivery regarding medical needs
A DSB client contacted CAP stating that the agency told her they would sponsor treatment for a malignant tumor around her optic nerve. She went through the treatment and was then denied assistance. At that time her medical bills totaled $149,697.70. The client was devastated and does not understand what happened. The CA investigated case by reviewing BEAM (their data collection system), speaking with the DSB Rehab Counselor (RC) and the Area Supervisor. The client was never put into a plan. The RC told her that the agency would sponsor it but apparently was not aware that it needed to be approved first by the agency physician and a plan had to be in place to authorize the services. The CA staffed the case with CAP Director because there are firewalls in the BEAM system to prevent back dating to prevent fraudulent activities and were unsure if the system could fix this. The CA called the VR BEAM System Administrator at DVRS (DSB and DVRS share the same data collection system) to see if it was possible before contacting the Director of DSB. She stated it could be done but would take a lot of work and needed to be approved by the Director. The CA called the DSB Director and explained the case and gave a timeline of what had happened, the understanding that the RC knew there was a sense of urgency but did not understand the process, the client stated that, even though the oncologist stated the radiation needed to start ASAP, she would have postponed treatment had she known the agency would not follow through. The CAP argued that the plan could have been put in place before the treatment began had the RC understood policy and the documentation requirements to provide the service. The director agreed and stated she would work with the field staff and the BEAM system administrator to fix this. The CA contacted the client to notify her of the agency decision. She cried with joy. All issues were resolved in the clients favor.
2. Reason: Service delivery regarding equipment needs
A DVRS client with mobility issues needs a new chair. She has been waiting for 10 months for a mobile chair from DVRS. She has a vehicle with a lift in the back to transport her current hovaround chair which is in disrepair. DVRS sent her to a vendor who provided a new chair but the one purchased will not fit in her car. Client was forced into signing for the chair by the vendor so "DVRS would pay them their money." Vendor will not give DVRS their money back and the dropped the chair at her house, won't fit in car or the house and is sitting in the elements. Instead of taking the loss, DVRS engineer is trying to get client a trailer but the amount of walking required to load and unload the chair is in conflict with her doctor's restrictions. She feels she has lost job opportunities due to delays that resulted in being provided a chair that is of no use. The CA researched the case. VR does not have a vendor that purchases hovaround chairs. No vendor product will fit in her vehicle so DVRS is trying to get a trailer which is not practical for client's medical conditions/restrictions. The CA spoke to the counselor who is very frustrated with management's decisions on how to resolve this case as they are more concerned about the $6,500 spent rather than meeting the client's needs. The CA called the head of purchasing. She stated if it is needed, DVRS can purchase any necessary product without having a contracted vendor as long as the cost is under $10,000. The CA spoke to UM and recommended they purchase a hovaround providing the procedural instructions. The recommendations were they pick up the $6500 chair that is sitting in the elements and store it until they find another client that the chair will meet their needs. UM agreed. All issues were resolved in the clients favor.
3. Reason: Communication
A DVRS client with a diagnosis of arthritis reached out to CAP for assistance with communication as no one from the agency would return her calls. DVRS sponsored hip surgery but forgot to write the authorization for post-op medications. The client was without medications for two days, trying to get DVRS to respond. The CA reviewed medical records in BEAM which stated that the client was advised by the doctor that she would have an extremely high risk for clots and a pulmonary embolism post-op. One of the prescribed medications is a blood thinner and the client reported excessive swelling in her leg. The CA called the Unit office. No one answered. The CA emailed the counselor, counselor in charge, and Assistant Regional Director as the Regional Director was on vacation. The CA got no response. As the situation was potentially life threatening and no one was responding, CA broke chain of command and reached out to the agency Director. The CA received no response from the director. The CA contacted the regional office and spoke with the administrative assistant to the Regional Director and explained the situation. She stated she would get in touch with the office and get the authorization written and sent to the pharmacy. The CA called client back to notify her. The CA also recommended the client go to the emergency room to make sure the swelling was not due to a clot. The client was reluctant as she did not have insurance. The CA explained that CAP would advocate to have DVRS pay the bill. The CA advised her to at least call the surgeon's office to get medical advice and to follow through with the advice. The client called back stating that the doctor informed her that she had a blood thinner patch on (she thought it was a pain patch) and that if the prescription was not filled today, she would need to go to the ER as the patch release of meds would end by evening. Medications were filled before 5:00 and all of the issues were resolved in the clients favor.
4. Administrative Review
Reason: Denial of Training
A DVRS client from the contacted CAP when he was denied receiving further financial support at the out of state school for the deaf for his degree in engineering. The agency stated he had exhausted the number of semesters of support DVRS policy allowed for in a Bachelor’s Degree program. The case record indicated that the client was an SSI recipient made eligible for DVR services based on communication problems due to deafness. He began working with DVRS in June of 2013 when he was a junior in high school, and the record showed at that time that he expressed interest in obtaining an engineering degree. Upon graduation from high school, VR provided financial support for the client in college and seemed to understand the progression of courses up until the time there was a change in Unit Managers (UM). The former UM was intimately involved with the client’s case, but when she left, the client was assigned to a different DVRS Counselor who did not have detailed knowledge of the client’s course of study. It was a rather complicated scenario, and in fairness to the counselor, she was also provided some incorrect information from the financial aid office about the number of semesters the client had left to complete. However, when the client tried to explain that he still had a number of courses left, there was no further investigation, and he was denied additional support. The counselor said he had reached the 10- semester maximum. After speaking with the client in January of this year, CAP reached out to the Chief of Policy and the current Unit Manager to request assistance for the spring 2020 semester and back payment for the previous semester in which the client did not receive DVRS support. Also, the agency had denied financial assistance with travel, which was previously on the plan, so the CA advocated for assistance with this as well. CAP explained that the client had to take additional courses based on placement testing, then earn the Associate’s Degree to meet the requirements for entrance into the Bachelor’s in Engineering Program, which is a 5-year program, so he was already in a longer than the typical Bachelor’s Degree plan. The UM agreed to speak with the client, but afterward determined that he should bear some of the responsibility for not maintaining contact with the agency. She was willing to ask the Chief of Policy to support an exception moving forward but would not be in support of assistance for the current semester nor the previous one. CAP disagreed with this, as the client had asked for clarification in writing for the denial just prior to the FA-19 semester, so he had no reason to make further contact with the agency since they were denying services.. He accepted their answer. The client decided to proceed with requesting an administrative review/appeal hearing, seeking back payment for FA-19 and SP-20, travel and financial support for his degree moving forward. CAP agreed to support/assist him in this. An Administrative Review was held. Through much back and forth and sharing of information with the reviewer, and CAP advocating on the client’s behalf, the client prevailed with his request. A Hearing was avoided. He was awarded back payment for travel as well as back payment for the 2019-20 school year in the amount of $20,000 plus dollars, which the client can now apply to his student loans. Furthermore, VR has agreed to support him in obtaining his Master’s Degree, as this semester there became a dual BS/MS option, and it would not take the client much longer to complete the MS than it would to complete the BS alone. The client is an excellent student with an above 3.0 GPA, and this will now allow him to reach his goals without a tremendous burden of debt. We are happy to have successfully resolved this case and all issues were resolved in the clients favor..
5. IL Administrative Review
Reason: Denied continued Personal Assistance services
The Legal Guardian (mother) of an IL client with a neurological disorder called requesting an appeal of Independent Living’s decision of Personal Assistance Services (PAS) to end on March 1, 2020. The client sustained a stroke at the age of 13 and has since lived with her mother who is now 85 years old. The client receives 82 hours per week of PAS services through the Community Alternatives Program - Innovations Waiver and 40 hours per week from IL. PAS staff provide services during day time hours. The mother stays up at night to monitor client who suffers seizures at night. She has difficulty swallowing and seizures while sleeping lead to risk of aspiration.
Mom reports that it is rare to get PAS workers to her home to staff the 82 hours. Client has a complex set of issues. She has an extreme sensitivity to sound and wears ear plugs at all times as noise is very agitating to her. She also has Tourette’s Syndrome. One manifestation of this is that she frequently spits which increases if she becomes agitated. As a result, it is difficult to get adequate, consistent staff for PAS services. It has also impacted how VR/IL staff view her.
The client has received PAS services through IL since 2014. Each year her financial eligibility has been assessed and approved as a family of one. In August of 2019, the IL counselor asked the mom is she claims the client on taxes. She stated she does as she always has. This requires that the financial eligibility be assessed as a family of two which made the client ineligible. The mom was very upset, stating she did not know she couldn’t claim her; she felt she is being punished for not knowing although she’s done nothing any different over the years. No one at IL ever asked or told her that claiming her would make the client ineligible. She did not feel it is fair for client’s services to be stopped.
The CA investigated the case. The case documentation indicates that this case was staffed with the QDS, MFP liaison, and Chief of Policy. It was determined that client did not meet financial need (even though she had for years). Client and Mom were told that services would end March 1st and that the client could reapply if mom did not claim her on 2019 taxes - however, she would then go on a lengthy wait list for services to resume. CA contacted UM to discuss issues. UM was not amenable to discussing case in detail because she stated the client was already getting 82 hours a week from CAP Innovations, and the case was staffed extensively with everyone and the decision by the Chief of Policy was final. She did not feel she could negotiate with CAP on this. Upon getting this response, the CA advised the legal guardian to take the next step in filing paperwork for an Administrative Review / Appeal Hearing, knowing that services cannot be disrupted while a case is moving through due process the CA asked if the legal guardian if she had filed taxes for 2019. She had not but did not intend to claim her daughter so she could get on the waiting list. The CA advised her to get the taxes done ASAP. Once done, client would meet eligibility.
The request for due process would delay the discontinuation of services and there would be no need to close the case, reapply, and go on a wait list. This would resolve the issue.
This case was much more complicated. CAP Innovations is considered a comparable benefit. However, after investigating, PAS hours from the waiver are not being provided to capacity. The client is typically only receiving 40 hours/week. The hours the mom is providing are at night, which is not in compliance with IL policy for PAS. Services should only be provided during daily activities while the client is awake. Medical records indicate need for monitoring while sleeping. Night shift has never been provided by PAS staffing agencies through the waiver, so mom does it. Mom is paid though iLife from IL for these services. The client pays a copay for the services though the waiver of $950/month. So, basically, the money mom gets replenishes the cost out of the client’s pricey copay deducted from her social security benefit. Ending the service through IL would put an extraordinary financial hardship on the family and mom states her daughter would then need to be moved into a long term care facility.
This could be a possible systemic issue with DMS (Division of Medical Assistance (DMA) and IL/MFP lack of collaboration/coordination to maximize services in the most cost-effective way for the agencies and the family. The allotted 122 hours a week is presumably too much as the family has sustained with much less for years. But the client exhausts her benefit check each month and only receives half the hours allocated through the waiver; therefore, not receiving the bang for her buck. The CA worked with the mom and IL to negotiate a solution during the administrative review. Final determination was that the client met financial eligibility and the service through IL would continue. CAP intervention therefore avoided the need for an Appeal Hearing. However, IL would work with the MCO (managed care organization) and family to set the client up as a “Self-determination” recipient of PAS. This would allow for the client to get 42 hours/week from a provider agency and the mom could be paid for the 40 hours at night through the waiver. Once that is established, IL can discontinue services, the family will remain financially whole, the client will not be institutionalized, and cost to the “system” is better utilized. The Administrative Review resolved the issues and the case was closed with all issues resolved in the clients favor.