372 - Annual Report on Home and Community-Based Services Waivers

UT
40183
SUBMITTED
Waiver Year:
Report Type:
$101,598 <= $190,098
Level/s of Care:
Note: Average Per Capita (APC)
Annual Number of Section 1915c Waiver Recipients and Expenditures:
(Specify each service as in the approved waiver)
Service
Service Name (no longer a required field): Level of Care Expenses in $ Participants Service Category Name
-- Other
If Other, specify:
Home Health Aide
NF $10,043 4
HCBS Taxonomy:
Category 1: Subcategory 1:
Category 2: Subcategory 2:
Category 3: Subcategory 3:
Category 4: Subcategory 4:
Service Name (no longer a required field): Level of Care Expenses in $ Participants Service Category Name
-- Other
If Other, specify:
Skilled Nursing Respite Care Agency
NF $2,251,468 120
HCBS Taxonomy:
Category 1: Subcategory 1:
Category 2: Subcategory 2:
Category 3: Subcategory 3:
Category 4: Subcategory 4:
Service Name (no longer a required field): Level of Care Expenses in $ Participants Service Category Name
-- Other
If Other, specify:
Skilled Nursing Respite Care Individual
NF $67,450 12
HCBS Taxonomy:
Category 1: Subcategory 1:
Category 2: Subcategory 2:
Category 3: Subcategory 3:
Category 4: Subcategory 4:
Service Name (no longer a required field): Level of Care Expenses in $ Participants Service Category Name
-- Other
If Other, specify:
Extended Private Duty Nursing
NF $122,330 7
HCBS Taxonomy:
Category 1: Subcategory 1:
Category 2: Subcategory 2:
Category 3: Subcategory 3:
Category 4: Subcategory 4:
Service Name (no longer a required field): Level of Care Expenses in $ Participants Service Category Name
-- Other
If Other, specify:
Family Directed Support
NF $0 0
HCBS Taxonomy:
Category 1: Subcategory 1:
Category 2: Subcategory 2:
Category 3: Subcategory 3:
Category 4: Subcategory 4:
Service Name (no longer a required field): Level of Care Expenses in $ Participants Service Category Name
-- Other
If Other, specify:
Financial Management Services
NF $5,856 13
HCBS Taxonomy:
Category 1: Subcategory 1:
Category 2: Subcategory 2:
Category 3: Subcategory 3:
Category 4: Subcategory 4:
Service Name (no longer a required field): Level of Care Expenses in $ Participants Service Category Name
-- Other
If Other, specify:
Family Support Services
NF $50,082 28
HCBS Taxonomy:
Category 1: Subcategory 1:
Category 2: Subcategory 2:
Category 3: Subcategory 3:
Category 4: Subcategory 4:
Service Name (no longer a required field): Level of Care Expenses in $ Participants Service Category Name
-- Other
If Other, specify:
In Home Feeding Therapy
NF $327 2
HCBS Taxonomy:
Category 1: Subcategory 1:
Category 2: Subcategory 2:
Category 3: Subcategory 3:
Category 4: Subcategory 4:
Assurances:
Documentation:
Findings of Monitoring:
Certification:
I, do certify that the information shown on the Form CMS-372(S) is correct to the best of my knowledge and belief:
Contact Information (optional):