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The department shall compute the utilization adjustment factor for each service by dividing the net costs of all claims paid for the service by the total of the authorized costs for that service, using at least 12 consecutive months of aggregate service data. The utilization adjustment factor shall be no lower than 60 percent. The department shall analyze and adjust the utilization adjustment factor at least annually in order to maintain cost neutrality. 5 ; Anticipated costs for home and vehicle modification are not subject to the average cost in subparagraph 2 ; or the utilization adjustment factor in subparagraph 3 ; . Costs for home and vehicle modification may be released in a one-time payment. 6 ; The individual budget amount may be changed only at the first of the month and shall remain fixed for the entire month. c. Required service components. To participate in the consumer choices option, a consumer must hire an independent support broker and must work with a financial management service that is enrolled as a Medicaid HCBS elderly waiver services provider. 1 ; Before hiring the individual support broker, the consumer shall receive the results of the background check conducted pursuant to 441--subrule 77.30 14 ; . 2 ; the consumer chooses to hire a person who has a criminal record or founded abuse report, the consumer assumes the risk for this action and shall acknowledge this information on Form 470-4289, HCBS Consumer Choices Informed Consent and Risk Agreement. d. Optional service components. A consumer who elects the consumer choices option may purchase the following services and supports, which shall be provided in the consumer's home or at an integrated community setting: 1 ; Self-directed personal care services. Self-directed personal care services are services or goods that provide a range of assistance in activities of daily living and incidental activities of daily living that help the consumer remain in the home and community. 2 ; Self-directed community supports and employment. Self-directed community supports and employment are services that support the consumer in developing and maintaining independence and community integration. 3 ; Individual-directed goods and services. Individual-directed goods and services are services, equipment, or supplies not otherwise provided through the Medicaid program that address a need identified in the consumer's service plan. The item or service shall decrease the consumer's need for other Medicaid services, promote the consumer's inclusion in the community, or increase the consumer's safety in the community. e. Development of the individual budget. The individual support broker shall assist the consumer in developing and implementing the consumer's individual budget. The individual budget shall include: 1 ; The costs of the financial management service. 2 ; The costs of the independent support broker. The independent support broker may be compensated for up to 6 hours of service for assisting with the implementation of the initial individual budget. After the initial implementation, the independent support broker shall not be paid for more than 20 hours of service during a 12-month period without prior approval by the department. 3 ; The costs of any services and supports chosen by the consumer as described in paragraph "d and altace, for instance, allphagan t.

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Many physicians are unaware that fecal incontinence is often correctable. With appropriate and relevant diagnostic tests, medical treatment and or surgical correction often leads to good functional results. General guidelines for diagnosis, evaluation, and management of fecal incontinence are provided. There are many causes of fecal incontinence, with obstetrical trauma being one of the most frequent. A detailed history, documentation of sphincter injury, and thorough physical examination will identify the cause of the problem in most patients. Management involves the use of antidiarrheal medication and fiber products, biofeedback, or enemas. A qualified surgeon should be consulted during the course of the patient's evaluation, particularly when medical therapy is unsuccessful. Knowledge of the appropriate diagnosis, evaluation, and management of fecal incontinence may result in more patients seeking medical attention and thus improving their quality of life. Mayo Clin Proc. 2002; 77: 271-275.

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