907 KAR 1:090. Personal care assistance waiver services.

907 KAR 1:090. Personal Care Assistance Waiver Services.

RELATES TO: 42 C.F.R. 441 Subparts B, G, 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 of Personal Care Assistance Waiver Services.

Section 1. Definitions. (1) "Applicant" means an individual who is applying for personal care assistance waiver services.

(2) "Business agent" means an entity nominated by an eligible individual to receive Medicaid payment to:

(a) Disburse to a personal care assistant; and

(b) Perform payroll functions.

(3) "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.

(4) "Department" means the Department for Medicaid Services or its designee.

(5) "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) Personal Care Assistance Waiver Services.

(6) "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.

(7) "Personal care assistance services" means the assistance by one (1) or more persons to an individual with a physical disability with tasks that the disabled individual would typically do for himself in the absence of a disability.

(8) "Personal care program coordination services" means an array of services that assist an eligible individual to become an effective employer of the personal care attendant.

(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 eighteen (18) or over with permanent or temporary recurring functional loss of two (2) or more limbs shall be eligible to participate in Personal Care Assistance 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 Medicaid Program established in 907 KAR 1:011.

(2) An individual shall not be eligible to participate in Personal Care Assistance Waiver Services if he:

(a) Is an inpatient of:

1. A hospital;

2. A nursing facility; or

3. An intermediate care facility for an individual with mental retardation or developmental disabilities;

(b) Is a recipient of services in another Medicaid waiver program; or

(3) Redetermination of eligibility factors pursuant to subsection (1) of this section shall occur at:

(a) Twelve (12) month intervals;

(b) More frequently if an individual’s condition or needs change; or

(c) When an individual reapplies for the Personal Care Assistance Waiver Services Program pursuant to Section 3(3)(a) or (c) of this administrative regulation.

Section 3. Services Provided to Eligible Individuals. (1) Pursuant to subsection (2) of this section, Personal Care Assistance Waiver Services shall include:

(a) Case management;

(b) Personal care assistance; and

(2) A service pursuant to subsection (1) of this section shall be covered if:

(a) Pursuant to Section 5(2)(h)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

(3) A service pursuant to subsection (1) of this section shall be:

(a) Terminated if an individual leaves the Personal Care Assistance Waiver Services Program;

(b) Suspended if an individual receives a temporary discharge from the Personal Care Assistance 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 Personal Care Assistance 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:

(1) Personal care assistance service; or

(2) Personal care program coordination service.

Section 5. Provider Responsibilities. (1) A provider of personal care assistance services shall:

(a) Assure that each staff person shall:

1. Be age eighteen (18) or older;

2. Demonstrate an ability to:

a. Read;

b. Write;

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 person’s personnel file;

4. Provide a current tuberculosis skin test with a copy of the test results filed in the staff person’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;

(b) Be:

1. Employed and supervised by the eligible individual; and

2. Monitored by a personal care program coordinator service provider pursuant to subsection (3) of this section;

(d) Report to work timely;

(e) Notify an eligible individual at least (6) six hours in advance if unable to report for work;

(f) Obtain and, as necessary, use emergency phone numbers and notify a program coordinator or case manager of conditions pursuant to the serious threat to the health, welfare, and safety of an eligible individual;

(g) Record daily:

1. The number of hours worked; and

2. The services rendered to an eligible individual; and

(h) Attend:

1. Training related to specific care needs of an eligible individual;

2. Staff meetings to monitor and coordinate services to an eligible individual with:

a. An eligible individual;

b. A program coordinator; and

c. A case manager.

(2) A provider of case-management services shall comply with subsection (1)(a)3 through 5 of this section and shall:

(a) Provide services throughout the geographic area covered under its plan;

(b) Treat an eligible individual in a respectful and dignified manner;

(d) Provide services in a safe manner;

(e) Maintain client confidentiality;

(f) Permit staff persons of the department to monitor and evaluate services provided;

(g) 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;

(h) Assure that:

1. Each office is:

a. Staffed to operate at least 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:

a. Qualification;

b. Certification; and

c. Training requirements;

3. Uniform procedures for verification of applicant 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 (m) of this subsection and recorded on form DSS 891-1,2 "Plan of Care", and the plan shall:

a. Relate to the assessed condition;

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 eligible individual and case-management team;

(i) Describe:

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:

a. Implementation;

b. Short-term goals; and

c. Long-term goals;

4. The manner in which services shall be delivered to an eligible individual including the units of service;

(j) 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 staffing plan accompanied by:

a. Current staff member’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 will provide message and referral services during:

a. Off hours; and

b. Weekends;

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 adults that have functional impairments and disabilities;

9. The provider’s plan to provide monitoring of:

a. Services; and

b. Quality of care provided to eligible individuals;

10. Documentation that interagency agreements with provider organizations within the geographic service area are signed and in place;

(k) Collect and report to the department, quarterly:

1. Summary data; and

2. Client-specific data;

(l) Comply with the appeal process pursuant to:

1. 907 KAR 1:560;

2. 907 KAR 1:563; and

3. 907 KAR 1:671;

(m) Perform an assessment of an 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 Personal Care Assistance Waiver 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-P "Kentucky Medicaid Program, Personal Care Assistance Waiver Services"; and

e. MAP-24 "Department of 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 related field, and has two years of work experience with elderly or physically disabled individuals; and

b. Registered nurse who possesses a current Kentucky nursing license;

(n) Document in an eligible individual’s case record:

1. The services provided pursuant to this administrative regulation; and

2. Each contact with the eligible individual or on his behalf;

(o) 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

(p) Assure that each case manager shall attend training as follows:

1. Fourteen (14) hours of case-management orientation training; and

2. Four (4) hours of in-service training, pertinent to the job function, quarterly.

(3) A provider of personal care program coordination services shall:

(a) Comply with subsection (1)(a) of this section;

(b) Employ or contract for a program coordinator who shall have:

1. Two (2) years equal to fifty-four (54) semester hours of college; or

2. Work experience in any of the following areas that shall substitute on a year-for-year basis:

a. Interviewing;

b. Community service;

c. Administrative;

d. Reviewing;

e. Monitoring;

f. Training; or

g. Eligibility determinations for human services programs;

1. Training in recordkeeping;

2. Tax responsibility instruction;

3. Supervision of a personal care assistant; and

4. Lists of personal care assistants from which the eligible individual may choose, if requested; and

(d) Provide monthly programmatic reports on personal care assistants upon the department’s request.

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)(h)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 confirmation notice, the case manager shall send the following documentation to the PRO:

(a) A DSS 891-1,2;

(b) A MAP 350;

(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) MAP-24 if services resume pursuant to Section 3(3)(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 personal care assistance 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 confirmation 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. 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 Personal Care Assistance Waiver Services providers from whom he wishes to receive services.

Section 8. 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 9. Incorporation by Reference. (1) The following material is incorporated by reference:

(a) MAP 10-P, Kentucky Medicaid Program Personal Care Assistance Waiver Services, January 2000 Revision;

(b) MAP-350, Long Term Care Facilities and Home and Community Based Program Certification Form, January 2000 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. 1874; Am. 2245; eff. 6-12-2000.)