INSTRUCTIONS FOR COMPLETING THE FORM THE AE MUST

This is a SAVEABLE PDF. Use the “SAVE” function to retain data entered. Data will be lost if you choose to use “SAVE AS.”
Request for the Provision of Emergency Respite Services
INSTRUCTIONS FOR COMPLETING THE FORM
Purpose: This form is used to request approval from the ODP Waiver Capacity Manager, WCM, to provide emergency respite
services in a licensed Community Home (55 Pa. Code Chapter 6400) beyond the waiver funded site’s approved program
capacity, or if respite is being proposed for a waiver participant in a non-waiver funded licensed residential setting.
Background: Effective July 1, 2009 waiver funded licensed Community Homes may only render services to individuals up
to the approved program capacity of the home. Approved program capacity is established by ODP for each waiver funded
residential habilitation setting licensed as a Chapter 6400 service location. Approved program capacity is based on the
maximum number of individuals who, on any given day, may be authorized to receive services at that site. There may be
situations in which a site’s licensed capacity is greater than the approved program capacity. In these situations, the site may only
provide services up to the approved program capacity.
On a case-by-case basis, ODP may approve the provision of emergency respite services above a waiver funded site’s approved
program capacity if the provision of respite is within the licensed capacity and does not result in the provision of services to a
maximum of eight individuals at the same time. ODP may also approve the provision of emergency respite services for a waiver
participant in a non-waiver funded licensed residential setting. An “emergency circumstance” is defined as a situation in which
one of the following criteria is met:
• An individual’s health and welfare is at immediate risk
• An individual experiences the sudden loss of their home (due to, for example, a fire or natural disaster).
This is not intended to replace a residential provider’s responsibility to secure an alternative if there is a need for
emergency relocation
• An individual loses the care of a relative/caregiver, without advance warning or planning
• There is an imminent risk of institutionalization
Written approval to provide respite services beyond the approved program capacity or to a waiver participant in a non-waiver
funded licensed residential setting must be obtained from the ODP Regional Waiver Capacity Manager before the provision of
respite occurs. Modifier U2 will be used with the respite procedure code both in the ISP and when the provider submits a claim
for the service.
Procedure: If an Administrative Entity, AE, or County Program identifies an emergency circumstance as defined as one of the
above, the AE/County Program will complete the top portion of the form to request approval from the Regional Waiver Capacity
Manager, WCM, to provide emergency respite.
THE AE MUST PROVIDE THE FOLLOWING INFORMATION ON THE FORM
AND SUBMIT THE FORM TO THE APPROPRIATE REGIONAL WCM:
Under the AE or County Information Section:
• The date of the request, the AE or County Program, and contact person including phone number and email address.
Under the Individual Information Section:
• The name, MCI #, current living situation, and current program enrollment/funding type of the individual in need of
emergency respite services
• A description of the emergency situation
• The expected duration of the emergency respite
• Validate that the individual and team’s preference is to use the setting for respite using the available licensed capacity
• The supports needed by the individual while in respite
Under the Provider Information Section:
• Provide Name, MPI#, Service Location, Approved Program Capacity and Licensed Capacity for the Provider which an
increase in program capacity is being requested
• Verify the Waiver Funded Licensed Residential Service provider is willing and qualified (as Provider Type 51, Home and
Community Habilitation) to provide the Respite service separate and discrete from the Residential Habilitation service
THE REGIONAL WCM WILL REVIEW THE INFORMATION PROVIDED BY THE AE AND DOCUMENT
THE FOLLOWING IN THE SHADED AREA OF THE FORM:
Under the WCM Notes/Actions Section:
• Verify that the emergency criteria are met and explain. If the emergency criteria are not met, the Regional WCM will
advise the AE/County Program to pursue alternative supports.
• Check if there are providers with a local vacancy available within the approved program capacity within their region or, if
necessary, other neighboring counties where the needed respite may be provided. Confirm that the providers are willing
and qualified to provide respite services as a provider type 51 and that they have the appropriate code selected as part of
their service offering. If they are not qualified or do not have the correct code selected as part of their service offering, then
the WCM will advise the AE/County Program that this needs to occur before any approval can be granted.
• WCMs should provide a current list of available providers with vacancies within approved program capacity that are
available for respite to the AE. Please note this field will expand to allow for additional text to be entered.
Under the WCM Approval/Disapproval and Explanation Section:
• If the AE/County Program determines that there is no appropriate vacancy within approved program capacity and the
criteria for an emergency is met, the Regional WCM may approve respite in a waiver funded licensed residential provider
location within the providers licensed capacity as long as
o The provider does not exceed the licensed capacity of the service location, and
o Use of the service location does not result in the provision of services to more than 8 individuals, or
o AE/County Program determines that a non-waiver eligible residential setting is to be used for emergency respite
(more than 8 individuals).
• The WCM will provide written confirmation to the AE/County Program and Provider on the approval. At this time, the AE/
County Program should work with the SCO to ensure that the ISP is updated and proceed with the service authorization.
• If disapproved, the WCM will advise the AE/County Program to secure alternative supports
This is a SAVEABLE PDF. Use the “SAVE” function to retain data entered. Data will be lost if you choose to use “SAVE AS.”
Request for the Provision of Emergency Respite Services
TO BE COMPLETED BY THE ADMINISTRATIVE ENTITY OR COUNTY PROGRAM:
AE or County Information
Date of Request: __________________ Name of AE/County Program: _________________________________________
AE or County Contact Person: _________________________________________________________________________
Phone Number: ______________________________ E-mail address: _________________________________________
Individual Information
Name of Person: _____________________________________________ MCI#:__________________________________
Current Living Situation: __________________ Current Program/Funding Type: _________________________________
Description of Emergency Situation including supports needed by the person: ____________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Expected Duration of Respite: From: _____________________ To: ___________________________
Are natural Supports Available: o YES o NO ___________ Team’s Desire to Use Setting Verified: o YES o NO
Supports Needed while in Respite:______________________________________________________________________
Provider Information
Provider Name and Address: __________________________________________________________________________
_________________________________________________________________________________________________
MPI#: _______________________________ Service Location #:_____________________________________________
Approved Program Capacity: _____________ Licensed Capacity:_____________________________________________
Provider Type 51 Specialty 513: o YES o NO
TO BE COMPLETED BY THE WAIVER CAPACITY MANAGER:
WCM Notes/Action
Is Emergency Criteria Met?: o YES o NO (If No, AE Should Pursue Alternative Supports)
Explain: ___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Is there a Local Vacancy Available within Approved Program Capacity? o YES o NO
If yes, where are vacancies available? ___________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
If there is not an appropriate local vacancy available within the approved program capacity and the criteria for an emergency are met, complete the following:
Will the provision of respite be Within Licensed Capacity: o YES o NO
Use of Location for Respite Results in Services to 8 individuals or less: o YES o NO
Use of Location for Respite in a non-waiver funded service setting (more than 8 individuals):
o YES o NO
*If yes, attach DP 1023 to document the approval of the exception to provide out-of-home respite in a non-waiver funded licensed residential setting to a waiver participant.
Specify any SSD or PROMISe™ Action Needed: __________________________________________________________
WCM Approval/Disapproval and Explanation
o APPROVED o DISAPPROVED Explanation: ________________________________________________________
_________________________________________________________________________________________________
If approved, identify the resulting census (approved program capacity plus respite bed):____________________________
Date of Written Confirmation to
AE or County: ___________________
Date Decision is
Logged/Recorded: ___________________
DP 1037 8/12