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Children’s Long-Term Support (CLTS) Provider Handbook

Section 11: Provider Service Compliance

A primary objective of the CLTS Program is supporting participants and their families in the community and promoting their health and safety.

This includes minimizing preventable risk. Strong, collaborative support networks must be in place to identify and remediate any risk to a participant’s well-being when it arises.

Section 1915(c) of the Social Security Act requires Home- and Community-Based Services (HCBS) waiver programs to provide assurances to the Centers for Medicare & Medicaid Services (CMS) that the safeguards necessary to protect the health and safety of program participants are in place. The assurances address unique challenges of providing services to participants living in their community:

  • Participants rely on many people for their care and safety.
  • Participants may be vulnerable and unable to seek help.

A CLTS provider has a responsibility to:

  • Prevent risk to participants’ well-being. Risk to well-being is also referred to as an “incident.”
  • Be a member of a strong, collaborative network that includes all the people in a participant’s life to promote their well-being and identify and mitigate risk when it arises.
  • Report and respond to incidents by contacting the CWA when they occur and if the participant is in immediate danger, by contacting local first responders.
  • Have a procedure in place for reporting participant incidents, abuse, or neglect.

What does DHS define as an incident involving a CLTS Program participant?

DHS defines a CLTS Program incident as one of five types of events:

Actual or alleged abuse, neglect, or exploitation involving the participant including:

  • Physical, verbal, and emotional abuse
  • Sexual abuse or exploitation
  • Neglect constituted by failure to seek medical attention, lack of food or nutrition, dangerous living situation, or lack of supervision
  • Financial exploitation constituted by misappropriation of the participant’s funds or property

Hospitalization, specifically due to:

  • An error in medical or medication management that results in an adverse reaction
  • A mental health condition

Law enforcement contact or investigation involving the participant when:

  • A participant’s contact with law enforcement is associated with risk to the health and safety of a participant or others
  • A participant’s law enforcement contacts are part of the participant’s crisis or behavior intervention plan

Unapproved use of restrictive measures including:

  • Misuse of mechanical restraint or protective equipment
  • Use of manual restraint
  • Use of isolation or seclusion
  • Death of the participant

There may be times when a provider encounters a situation they feel may involve risk to a participant that is not on this list. Participant safety is vital in the CLTS Program. Providers are encouraged to reach out to the SSC any time they have concerns regarding risk to a participant.

Abuse or neglect

Providers should report child abuse or child neglect to the SSC if they suspect that:

  • The child has been abused or neglected.
  • The child has been threatened with abuse or neglect.
  • Abuse or neglect may occur.

Wisconsin’s mandated reporter statute Wisconsin Legislature: 48.981(2) defines who must report child abuse or neglect to CPS and law enforcement, not just to a waiver agency, under state law.

For information on child abuse and neglect prevention, see Preventing Child Abuse (PDF).

How do I report an incident?

The SSC will inform you of CWA incident reporting requirements, including contact information for submitting the report.

Once you have reported an incident, the CWA is required to:

  • Refer allegations of child abuse and neglect to the county child protective services agency or the local law enforcement agency for further investigation, if applicable.
  • Work closely with the family to reduce further risk to the participant and prevent other children from being harmed.
  • Implement changes identified in the service plan.
  • Report incidents to the Wisconsin Department of Health Services.

Complaints and grievances

Providers are responsible for maintaining program standards and ensuring quality service delivery. If there are issues regarding providers not acting in alignment with CLTS Program standards, the first step is to try to resolve them through clear communication among SSCs, families, and providers. If there are complaints or grievances that cannot be resolved regarding provider quality, DHS CLTS Provider Relations becomes involved.

They work with policy, billing, and legal experts to investigate and resolve widespread issues related to:

  • Fraudulent behavior, such as billing for services that a child didn’t receive.
  • Violation of participant rights, such as the use of restrictive measures.
  • Health and safety violations, such as facility hazards that can seriously injure a participant.
  • Service misalignment, such as providing services not covered by the CLTS Program.

Investigation, remediation, and termination process

When the CLTS Program Provider Relations inbox receives a complaint about a provider, DHS Provider Relations follows up with the provider to discuss the complaint. DHS then reviews the complaint to determine if further investigation is needed. If the decision is made that further investigation is necessary, DHS will contact the provider by phone and email.

Investigations may involve:

  • Requesting relevant documentation.
  • Proof that background checks were completed.
  • Emergency plans.
  • Service licensing and training.
  • Case notes or progress reports.

An investigation may result in conducting provider education regarding benefit policy and service delivery standards.

If a concern or issue is determined to meet the criteria of termination, the provider will be notified with both a notice of termination and notice of enrollment termination letter by certified mail. The notice will include information about the provider’s appeal rights and detail the results of the investigation.

DHS then removes the provider from the CLTS Program Provider Registry. The provider’s Medicaid enrollment will end on the termination date. The provider will be barred from the program for five years.

CWAs will also be notified of the provider’s termination date.

Glossary