907 KAR 1:070. Homecare Waiver Services.
RELATES TO: 42 C.F.R. 441 Subpart G, Subpart B, 42 U.S.C. 1396a, b, d, n
STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3), EO 2004-726
NECESSITY, FUNCTION, AND CONFORMITY: EO 2004-726, effective July 9, 2004, reorganized the Cabinet for Health Services and placed the Department for Medicaid Services and the Medicaid Program under the Cabinet for Health and Family Services. The Cabinet for Health and Family Services, Department for Medicaid Services, is required to administer the Medicaid Program. KRS 205.520(3) authorizes the cabinet to comply with any requirement that may be imposed, or opportunity presented, by federal law for the provision of medical assistance to Kentucky’s indigent citizenry. This administrative regulation establishes the provisions for Homecare Waiver Services.
Section 1. Definitions. (1) "Applicant" means an individual who is applying for Homecare Waiver Services.
(2) "Case management" means:
(a) Services that oversee the application, assessment, and reassessment of individuals for waiver services; and
(b) A system under which responsibility for locating, coordinating and monitoring a group of services rests with a designated person.
(3) "Department" means the Department for Medicaid Services or its designee.
(4) "Eligible Individual" means a person who has applied for medical assistance and has been determined to have met all applicable conditions for eligibility, pertaining to:
(a) Kentucky’s Medicaid Program; and
(b) Homecare Waiver Services.
(5) "Environmental accessibility adaptation" means a physical adaptation to the home that is required by the individual’s plan of care that is necessary to ensure the health, welfare and safety of the individual.
(6) "Homemaker services" means an array of services consisting of general household activities provided by a trained homemaker.
(7) "Participating" means a provider of medical services taking part in the Medicaid Program by agreeing to comply with program administrative regulations and providing services to eligible recipients.
(8) "Personal care services" means assistance with activities of daily living or related housekeeping chores.
(9) "PRO" means a peer review organization which is under contract with the department.
(10) "Provider" is defined in KRS 205.8451(7).
(11) "Staff person" means an employee or volunteer of a provider or agency who provides the direct delivery of services to an eligible individual.
Section 2. Individual Eligibility Determination and Redetermination. (1) An individual aged sixty (60) or over shall be eligible to participate in Homecare Waiver Services if he meets the:
(a) Nursing facility (NF) level of care requirements pursuant to 907 KAR 1:022; and
(b) Technical and financial eligibility criteria of Kentucky’s Medical Assistance Program established in 907 KAR 1:011.
(2) An individual shall not be eligible to participate in Homecare Waiver Services if he is:
(a) An inpatient of:
1. A hospital;
2. A nursing facility; or
3. An intermediate care facility for individuals with mental retardation or developmental disabilities; or
(b) A recipient of services in another Medicaid waiver program.
(3) Redetermination of eligibility factors pursuant to subsection (1) of this section shall occur:
(a) At twelve (12) month intervals;
(b) More frequently if the individual’s condition or needs change; or
(c) When an individual reapplies for the Homecare Waiver Services Program pursuant to Section 3(4)(a) or (c) of this administrative regulation.
Section 3. Services Provided to an Eligible Individual. (1) Pursuant to subsection (3) of this section, Homecare Waiver Services shall include:
(a) Case management;
(c) Personal care; and
(d) Pursuant to subsection (2) of this section, environmental accessibility adaptations.
(2) Environmental accessibility adaptations shall:
(a) Meet all applicable state or local building codes;
(b) Be limited to a maximum of $1,000 per eligible individual per calendar year; and
(c) Exclude adaptations or improvements to the home that:
1. Have no direct medical or remedial benefit to the individual; and
2. Add to the total square footage of the home.
(3) A service pursuant to subsection (1) of this section shall be covered if:
(a) Pursuant to Section 5(2)(a)4 of this administrative regulation, it is entered on form DSS 891-1,2 "Plan of Care", and approved by the department;
(b) The service is prior authorized by the department using form MAP 9 "Kentucky Medicaid Program, Prior Authorization for Health Services"; and
(c) It is managed and coordinated by a provider or agency.
(4) A service pursuant to subsection (1) of this section shall be:
(a) Terminated if an individual leaves the Homecare Waiver Services Program;
(b) Suspended if an individual receives a temporary discharge from the Homecare Waiver Services Program pursuant to Section 2(2)(a) of this administrative regulation for not more than sixty (60) consecutive days; or
(c) Resumed if an individual, pursuant to paragraph (b) of this subsection, returns to the Homecare Waiver Services Program within sixty (60) days.
Section 4. Exclusions for Provider Participation. A provider of case management shall not be an eligible provider of a service pursuant to Section 3(1)(b) through (d) of this administrative regulation.
Section 5. Provider Responsibilities. (1) A provider of personal care and homemaker services shall:
(a) Provide services throughout the geographic area covered under its plan;
(b) Treat the client in a respectful and dignified manner;
(c) Involve the client and caregiver in the delivery of services;
(d) Provide services in a safe manner;
(e) Permit staff of the department to monitor and evaluate services provided;
(f) Maintain written:
1. Job descriptions for each position;
2. Qualifications of staff;
3. Training standards;
4. Personnel policies; and
5. Wage scales for each job category;
(g) Provide professional on-site supervision of staff:
1. One (1) time per month; or
2. More frequently, as determined by the supervisor; and
(h) Assure that all staff shall:
1. Be age eighteen (18) or older;
2. Demonstrate an ability to:
c. Understand instructions;
d. Carry out instructions;
e. Record messages;
f. Keep simple records; and
g. Maintain client confidentiality;
3. Not have been convicted of a felony as evidenced by a valid criminal records’ investigation report obtained from the Kentucky Justice Cabinet and maintained in the staff’s personnel file;
4. Provide a current tuberculosis skin test with a copy of the test results filed in the staff’s personnel file; and
5. Not serve clients if the staff person has contracted an infectious disease of any nature until his condition is determined not to be contagious as supported by a physician’s statement submitted to the provider by the staff person.
(2) A provider of case-management services shall comply with subsection (1)(a) through (h) of this section; and
(a) Assure that:
1. Each office is:
a. Staffed to operate thirty-seven and one-half (37.5) hours per week during normal working hours; and
b. Accessible to persons who are disabled;
2. Each case manager and case-management supervisor shall meet:
b. Certification; and
c. Training requirements;
3. Uniform procedures for verification of client eligibility and case management are used; and
4. An eligible individual served by the provider shall receive services pursuant to a care plan developed cooperatively with a case-management team, pursuant to paragraph (f) of this subsection and recorded on form DSS 891-1,2 "Plan of Care", and the plan shall:
a. Relate to the assessed problem;
b. Identify the:
(i) Goals to be achieved;
(ii) Scope, duration and units of service; and
(iii) Source of services;
c. Incorporate a reassessment plan; and
d. Be signed by the client and case-management team;
1. Its methods for referring an eligible individual to other appropriate programs and services;
2. Its program monitoring procedures;
3. Its case-management plan, including:
b. Short-term goals; and
c. Long-term goals; and
4. The manner in which services shall be delivered to an eligible individual, including the units of service;
(c) Provide the following information regarding its organizational structure:
1. A description of its legal identity, documented by the following items:
a. Articles of incorporation;
b. Mission statement;
c. Bylaws; and
d. Intergovernmental agreements (if applicable);
2. Its governing board membership;
3. An organizational chart;
4. A description of its case-management services staffing plan accompanied by:
a. Current staff’s resumes; and
b. The number of full time equivalents (FTE’s) for each position type;
5. A description of its telephone system including an explanation of how it shall provide message and referral services during:
a. Off hours; and
6. Its procedures which govern financial responsibility:
7. Financial statements and an independent audit for the previous year;
8. The provider’s experience in working with the population aged sixty (60) and older that have functional impairment and disabilities;
9. The provider’s plan to provide monitoring of:
a. Services; and
b. Quality of care provided to an eligible individual;
10. Documentation that interagency agreements with provider organizations within the geographic service area are signed and in place;
(d) Collect and report to the department, quarterly:
1. Summary data; and
2. Client-specific data;
(e) Comply with the appeal process pursuant to:
1. 907 KAR 1:560;
2. 907 KAR 1:563; and
3. 907 KAR 1:671;
(f) Perform an assessment of an eligible individual:
1.a. At the initial contact with a case manager; and
b.(i) Every twelve (12) months thereafter;
(ii) More frequently if an individual’s condition or needs change; or
(iii) When an individual requests readmission to the Homecare Waiver Services Program;
2. Using the following forms:
a. DSS 891-1,2;
b. MAP 350 "Long Term Care Facilities and Home and Community Based Program Certification";
c. "State of Kentucky Aging Services Client Enrollment";
d. MAP 10-H "Kentucky Medicaid Program Home and Community Based Services Waiver"; and
e. MAP-24 Department for Community Based Services form; and
3. By a team consisting of a:
a. Social worker who possesses a:
(i) Bachelor or master’s degree in social work, gerontology, psychology, sociology or a related field; or
(ii) Bachelor’s degree in a field other than social work, gerontology, psychology, sociology or a related field and has two (2) years of work experience with the elderly or with physically disabled individuals; and
b. Registered nurse who possesses a current Kentucky nursing license;
(g) Provide bimonthly on-site monitoring by a case-management team member to assure that an eligible individual’s needs, as identified in the care plan, are met; and
(h) Document in an eligible individual’s case record:
1. The services provided pursuant to this administrative regulation; and
2. Each contact with, or on behalf of, an eligible individual.
(3) A provider of environmental accessibility adaptations shall be:
(a) An individual contractor or agency; and
(b) Licensed in accordance with state and county building codes in the counties in which they work.
Section 6. Applicant Level of Care Determination Process. (1) Pursuant to Section 2(1)(a) of this administrative regulation, a case-management team member shall telephone the PRO and provide required applicant information pursuant to Section 5(2)(a)4 of this administrative regulation.
(2) If the PRO determines that an applicant meets nursing facility level of care requirements, the PRO shall:
(a) Verbally notify a case manager of its determination; and
(b) Send written confirmation of its determination to the case manager.
(3) Upon receipt of the PRO’s written confirmation, the case manager shall send the following documentation to the PRO:
(a) A DSS 891-1,2;
(b) A MAP 350;
(c) A MAP 10H;
(d) A "State of Kentucky Aging Services Client Enrollment" form;
(e) A confirmation notice stating that the applicant meets nursing facility level of care requirements; and
(f) A MAP-24 if services resume pursuant to Section 3(4)(c) of this administrative regulation.
(4) Upon receipt of the items listed in subsection (3) of this section, the PRO shall generate a document approving or denying the applicant for each homecare waiver service requested.
(5) The department shall ensure that this document is forwarded to:
(a) Each homecare waiver service provider; and
(b) The applicant.
(6) If the PRO determines that the applicant does not meet nursing facility level of care requirements, the PRO shall:
(a) Verbally notify the case manager of its determination; and
(b) Send written notification of its decision to:
1. The case manager;
2. The Department for Community Based Services; and
3. The applicant, whose notification shall contain appeal right information.
Section 7. Training Requirements. (1) Personal care and homemaker services training shall:
(a) Be conducted by:
1. A recognized institution of learning; or
2. If by the employing agency, one (1) or more professional specialists, who shall be:
a. A nurse;
b. A social worker;
c. A home economist;
d. A nutritionist or dietitian; and
e. A personal care or homemaker employer;
(b) Include sixty (60) hours of comprehensive training as follows:
1. Sixteen (16) hours of training shall be completed by staff prior to any work assignments and:
a. Shall include:
(i) An overview of the Office of Aging Services;
(ii) The role of the personal care and homemaker staff;
(iii) Recordkeeping and confidentiality; and
(iv) A supervised home visit with an experienced personal care or homemaker staff for a period of four (4) hours;
b. Instruction shall:
(i) Be provided to new staff within the first week of employment; and
(ii) Include communication techniques appropriate to working with older people.
c. Instruction shall be provided within the first month of employment and shall include how to:
(i) Maintain a clean and safe environment; and
(ii) Respond to hazards; and
2. Forty-four (44) hours shall be completed within the initial six (6) months of employment which shall include:
a. Food and nutrition;
b. Personal care;
c. Basic first aid; and
(c) Include a minimum of six (6) hours of continuing education training for staff who perform personal care and homemaker job functions pursuant to Section 1(6) and (8) of this administrative regulation. This training shall be provided:
1. By an employing provider each fiscal year; and
2. On topics appropriate to the job functions of a personal care or homemaker staff; and
(d) Be documented in a staff member’s personnel file by an employing agency, including:
1. A staff member’s attendance;
2. A staff member’s number of hours credit;
3. The subject matter of the training;
4. A course outline;
5. An instructor’s name and title; and
6. A staff member’s test results.
(2) Case managers shall be required to attend:
(a) Fourteen (14) hours of case-management orientation training; and
(b) Four (4) hours of continuing education training, pertinent to the job function, on a quarterly basis.
Section 8. Recipient Choice. (1) An eligible individual or his legal representative shall:
(a) Be given a choice to receive:
1. Home and community based services; or
2. Nursing facility services subject to the limitations established in Section 2 of this administrative regulation; and
(b) Pursuant to paragraph (a)1 and 2 of this subsection, complete, sign, and date form MAP 350.
(2) An eligible individual or his legal representative shall select participating Homecare Waiver Services providers from whom he wishes to receive services.
Section 9. Appeal Rights. (1) An appeal of a negative action regarding Medicaid eligibility of an individual shall be in accordance with 907 KAR 1:560.
(2) An appeal of a negative action regarding NF level of care or a service to a Medicaid beneficiary shall be in accordance with 907 KAR 1:563.
(3) An appeal of a negative action regarding a Medicaid provider shall be in accordance with 907 KAR 1:671.
Section 10. Incorporation by Reference. (1) The following material is incorporated by reference:
(a) MAP 10-H, Kentucky Medicaid Program Homecare Waiver Services, January 2000 Revision;
(b) MAP-350, Long Term Care Facilities and Home and Community Based Program Certification Form, January 2000 Revision;
(c) MAP-9, Kentucky Medicaid Program, Prior Authorization for Health Services, December 1995 Revision;
(d) DSS 891-1,2, The Plan of Care, July 1996 Revision;
(e) The State of Kentucky, Aging Services Client Enrollment, January 2000 Revision; and
(f) MAP-24, Department for Community Based Services form, January, 2000 Revision.
(2) This material may be inspected, copied, or obtained at the Department for Medicaid Services, 275 East Main Street, Frankfort, Kentucky 40621, Monday through Friday, 8 a.m. to 4:30 p.m. (26 Ky.R. 1869; Am. 2242; eff. 6-12-2000.)