13 CSR 70-91.010
Personal Care Program
PURPOSE: Personal care services are medically-oriented services
provided in the individual’s home, or in a licensed Residential
Care Facility I or II to assist with activities of daily living to meet
the physical needs of the individual. Personal care services are
authorized by a physician in accordance with a plan of care or
otherwise authorized in accordance with a service plan approved
by the state. This rule establishes the basis for administering
the personal care program, including the criteria providers of
the service must meet, criteria a recipient of the service must
meet, and criteria and method of reimbursement for the services.
Specific details of the amount, duration, scope, and limitations of
services covered are included in the provider program manuals.
(1) Persons Eligible for Personal Care Services. Any person
who is determined eligible by the Family Support Division
for Title XIX benefits and is found to be in medical need of
personal care services as an alternative to institutional care.
Persons must be assessed, approved, and case-managed by the
Department of Health and Senior Services or its designee as
described in this rule to be eligible for personal care services.
Eligibility procedures for personal care services are as follows:
(A) Requirements for Personal Care Services.
1. The participant must need an institutional level of care
which is defined as twenty-four- (24-) hour institutional care on
an inpatient or residential basis in a hospital or nursing facility
(NF) and approved by the Department of Health and Senior
Services or its designee.
2. Level of care will be determined by the Department of
Health and Senior Services or its designee.
3. The participant must agree to an in-home assessment
performed by the Department of Health and Senior Services or
its designee of his/her physical, social, and functional ability to
benefit from personal care services;
(B) Obtaining Personal Care Services.
1. If the participant meets all of the eligibility and
assessment criteria, the Department of Health and Senior
Services or its designee will develop an initial personal care
plan to authorize personal care services on a scheduled basis to
eligible participants in their own homes, licensed Residential
Care Facilities (RCFs) I or II, or Assisted Living Facilities (ALFs)
as an alternative to twenty-four- (24-) hour institutional care
on an inpatient or residential basis in a hospital or NF. The
Department of Health and Senior Services or its designee will
forward a copy of the personal care plan to the participant’s
attending physician and to the personal care provider who will
be delivering care. Upon the receipt of the personal care plan,
the provider of care must initiate care within ten (10) calendar
days of receipt and the physician must register any comments
or requests for changes within thirty (30) days of receipt or the
personal care plan will stand as written by the Department of
Health and Senior Services or its designee.
2. The personal care plan will be developed in collaboration
with and signed by the participant. The plan will include
an identification of the services and tasks to be provided,
frequency of services, and the maximum number of units of
service for which the participant is eligible per month.
3. A new in-home assessment and personal care plan may
be completed by the Department of Health and Senior Services
or its designee as needed to redetermine need for personal
care services or to adjust the monthly amount of authorized
units. The service provider must always have an active service
plan. Only the Department of Health and Senior Services or its
designee, not the service provider, may increase the overall
maximum number of units for which the individual is eligible
per month. Any service plan developed in accordance with
paragraphs (1)(B)2. and 3. is a state-approved service plan.
4. The participant will be informed of the option of
services available to him/her in accordance with the level-ofcare determination and assessment findings; and
(C) Discontinuing Personal Care Services. The following
policies and procedures for discontinuing personal care
services shall be followed:
1. Services for a participant shall be discontinued by a
provider agency under the following circumstances:
A. When the participant’s case is closed by the
Department of Health and Senior Services or its designee;
B. When the provider learns of circumstances that
require the closure of a case for reasons including but not
limited to death entry into a nursing home, or the participant
no longer needs services. In these circumstances, the provider
shall notify the Department of Health and Senior Services or its
designee in writing and request that the participant’s services
be discontinued;
C. When the participant is noncompliant with the
agreed-upon plan of care. Noncompliance requires persistent
actions by the participant or family which negate the
services provided by the agency. After all alternatives have
been explored and exhausted, the provider shall notify the
Department of Health and Senior Services or its designee
in writing of the noncompliant acts and request that the
participant’s services be discontinued;
D. When the participant or participant’s family threatens
or abuses the personal care aide or other agency staff to the
point where the staff’s welfare is in jeopardy and corrective
action has failed. The provider shall notify the Department of
Health and Senior Services or its designee of the threatening
or abusive acts and may request that the service authorization
be discontinued;
E. When a provider is unable to continue to meet the
maintenance needs of a participant. In these circumstances,
the provider shall notify the Department of Health and
Senior Services or its designee in writing and request that the
participant’s services be discontinued; or
F. When a provider is unable to continue to meet the
maintenance needs of a participant whose plan of care requires
advanced personal care services. In these circumstances the
provider shall provide written notice of discharge to the
participant or participant’s family and the Department of
Health and Senior Services or its designee at least twenty-one
(21) days prior to the date of discharge. During this twentyone- (21-) day period, the Department of Health and Senior
Services or its designee shall assist in making appropriate
arrangements with the participant for transfer to another
agency, institutional placement, or other appropriate care.
Regardless of circumstances, the personal care provider must
continue to provide care in accordance with the plan of care
for these twenty-one (21) days or until alternate arrangements
can be made by the Department of Health and Senior Services
or its designee, whichever comes first; and
2. Discontinuing services for a participant still in need of
assistance shall occur only after appropriate conferences with
the Department of Health and Senior Services or its designee,
participant, and participant’s family.
(2) Basic personal care services are medically-oriented, maintenance services to assist with the activities of daily living when
this assistance does not require devices and procedures related
to altered body functions.
(A) To be eligible for basic personal care, an individual
must be in need of personal care services as an alternative to
institutional care as specified in section (1) of this rule.
(B) The following activities constitute basic personal care
services and shall be provided according to the plan of care:
1. Assistance with dietary needs, including meal
preparation and cleanup, and assistance with eating/feeding;
2. Assisting with dressing and grooming, including helping
with dressing and undressing, combing hair, and nail care;
3. Assisting with bathing and personal hygiene, including
assisting with bathing, shampooing hair, oral hygiene and
denture care, and shaving;
4. Assisting with toileting and continence, including
assisting in going to the bathroom, and changing bed linen.
This category may also include the changing of beds for
persons with medically related limitations that prohibit the
completion of this task;
5. Assisting with mobility and transfer, including assisting
with transfer and ambulation when participants can at least
partially bear own weight;
6. Assisting with medication, including assisting with
the self-administration of medicine, applying nonprescription
topical ointments or lotions; and
7. Medically related household tasks, including approved
homemaker and chore tasks.
(C) The encouragement and instruction of participants in selfcare may be a component of any other task as described above;
however, encouragement and instruction do not constitute a
task in and of themselves.
(3) Criteria for Providers of Personal Care Services.
(A) The provider of personal care services must have a
valid participation agreement with the Department of Social
Services, Missouri Medicaid Audit and Compliance Unit. The
issuance of the participation agreement is dependent upon
acceptance of an application for enrollment by the Missouri
Medicaid Audit and Compliance Unit. The provider must
submit to the Missouri Medicaid Audit and Compliance Unit
the written proposal required to become a Title XX in-home
services provider and be approved to provide Title XX in-home
services. Once approved to provide Title XX in-home services
by the Missouri Medicaid Audit and Compliance Unit, the
provider will be allowed to execute a Title XIX participation
agreement with the Missouri Medicaid Audit and Compliance
Unit. Thereafter, a provider is not required to actually accept
or deliver services to participants who are authorized for both
programs or to participants who are authorized for Title XX
services only. For residential care facilities that wish to provide
services only to the eligible residents of their own facility,
only the verification of a state residential care facility license
authorized by the Department of Health and Senior Services,
Division of Regulation and Licensure, will be required for the
Medicaid enrollment application. Providers must maintain
their approval to participate as a Title XX provider, whether or
not they actually serve Title XX eligible participants, in order
to remain qualified to participate in the Title XIX (Medicaid)
Personal Care Program.
(B) The providers must agree to comply with any evaluation
conducted by the Missouri Medicaid Audit and Compliance
Unit. The Missouri Medicaid Audit and Compliance Unit may,
in accordance with the protective service mandate (Chapter
192, RSMo), take action to protect participants from providers
who are found to be out of compliance with the requirements
of its regulations and of any other regulations applicable to
the Personal Care Program, when such noncompliance is
determined by the Missouri Medicaid Audit and Compliance
Unit to create a risk of injury or harm to participants. Evidence
of such risk may include unreliable or inadequate provider
documentation of services or training due to falsification or
fraud, the provider’s failure to deliver services in a reliable
and dependable manner, or use of personal care aides who do
not meet the minimum training standards of this regulation.
Immediate action by the Missouri Medicaid Audit and
Compliance Unit may include but is not limited to—
1. Removing the provider from any list of providers and,
for participants who request the unsafe and noncompliant
provider, informing the participants of the determination
of noncompliance after which any informed choice will be
honored by the Department of Health and Senior Services or
its designee; or
2. Informing current participants served by the provider of
the provider’s noncompliance and that the Division of Senior
and Disability Services has determined the provider unable to
deliver safe care. Such participants will be allowed to choose a
different provider from the list maintained by the Department
of Health and Senior Services or its designee, which will then
be immediately authorized to provide service to them.
(C) The provider agency must be available to provide care
in accordance with the personal care plan, utilizing universal
precaution procedures as defined by the Centers for Disease
Control and Prevention.
(D) The provider agency must monitor the overall physical
care needs of the participant. If the participant’s condition
warrants, contact the participant’s physician and inform the
Department of Health and Senior Services or its designee when
additional case management activities by the Department of
Health and Senior Services or its designee are required.
1. Prior to the delivery of service, the personal care aide
shall receive a copy of the care plan for the participant and
be provided with information about the participant in order
to appropriately deliver services to meet the needs of the
participant.
(E) For newly employed aides, the provider agency must, at
a minimum, provide twelve (12) hours of orientation training,
within thirty (30) days of employment.
1. In calculating these hours, the following requirements
shall apply:
A. At least two (2) hours orientation to the provider
agency and the agency’s protocols for handling emergencies;
B. With a minimum of six (6) hours of training being
completed prior to participant contact;
C. Four (4) hours of required orientation may be waived
with adequate documentation in the employee’s records that
the aide received similar training during the previous twelve
(12) months, with the exception of the statutorily required
dementia training;
D. If an aide is a certified nurse assistant (CNA), licensed
practical nurse, or registered nurse, the provider agency may
waive all hours of orientation training, with the exception of the
two (2) hours’ provider agency orientation and the statutorily
required dementia training, with adequate documentation
placed in the aide’s personnel record. The documentation shall
include the employee’s license or certification number, which
must be current and in good standing at the time the training
was waived.
2. An additional five (5) hours of in-service training
annually are required after the first twelve (12) months of
employment. The provider may waive the required annual five
(5) hours of in-service training and require only two (2) hours of
refresher training annually when the aide has been employed
for three (3) years and has completed fifteen (15) hours of inservice training. In-service training curricula shall include
updates on Alzheimer’s disease and related dementia.
3. Personal care aides employed by an RCF II or ALF are
exempt from the training requirements defined in paragraphs
(3)(E)1. and 2. of this rule if they have completed the training
requirements described in subdivisions (9) and (10) of subsection
3 of section 198.073, RSMo.
4. The provider agency shall have written documentation
of all basic and in-service training provided which includes,
at a minimum, a report of each employee’s training in that
employee’s personnel record. The report shall document the
dates of all classroom or on-the-job training, trainer’s name,
topics, number of hours and location, the date of the first
participant contact, and shall include the aide’s signature.
If a provider waives any in-service training, the employee’s
training record shall contain supportive data for the waiver.
(F) The requirements that have been adopted by the Division
of Senior and Disability Services at 19 CSR 15-7.021(18)(A)
through (Q) and (18)(T) through (W) shall apply to all providers
of personal care services and advanced personal care services.
(G) The provider agency must employ an administrative
supervisor of the day-to-day delivery of direct personal care
services possessing at least the following qualifications:
1. Be at least twenty-one (21) years of age; and
2. Shall be a registered nurse (RN) who is currently licensed in Missouri; or have at least a baccalaureate degree; or
be a licensed practical nurse (LPN) who is currently licensed
in Missouri with at least one (1) year of experience with the
care of the elderly, or individuals with disabilities or medically
complex conditions; or have at least two (2) years’ experience
with the care of the elderly, or individuals with disabilities or
medically complex conditions.
(H) The supervisor’s responsibilities shall include, at a
minimum, the following:
1. Establish, implement, and enforce a policy governing
communicable diseases that prohibits provider staff contact
with participants when the employee has a communicable
condition, including colds or flu. Assure that reporting
requirements governing communicable diseases, including
hepatitis and tuberculosis, as set by the Missouri Department of
Health and Senior Services (19 CSR 20-20.020), are carried out;
2. Monitor the provision of services by the personal
care worker to assure that services are being delivered in
accordance with the personal care plan. This shall be primarily
in the form of an at least monthly review and comparison of
the worker’s records of provided services with the personal
care plan. The monitoring reports shall be available for review
by the Departments of Social Services and Health and Senior
Services upon request. Documentation, including the reason,
must be kept on authorized services/units not delivered;
3. Make an on-site visit at least annually to evaluate each
personal care worker’s performance and the adequacy of the
service plan, including review of the plan of care with the
participant. The personal care worker may or may not be present
for this evaluation. A written record of the evaluation shall be
maintained in the personnel file of the personal care worker.
This record must contain, at a minimum, the participant’s
name and address, the date and time of the visit, personal
care worker’s name, observations related to the participant’s
receipt of care plan delivery, the participant’s satisfaction of
the personal care worker’s performance, and the adequacy of
the service plan. In addition, the evaluation shall be signed and
dated by the supervisor who prepared it and by the personal
care worker. If the required evaluation is not performed or
not documented, the personal care worker’s qualifications
to provide the services may be presumed inadequate and all
payments made for services by that personal care worker may
be recouped;
4. Approve, in advance, all changes to the plan of care based
on supervisory on-site visits, information from the personal
care worker, or observation by the RN, or a combination of
these. Approval of changes shall be noted and dated in the
participant’s file;
5. Make appropriate recommendations to the Department
of Health and Senior Services or its designee including
proposed increase, reduction, or termination of services; or
need for increased Department of Health and Senior Services
involvement based on supervisory on-site visits, review of
reports, information from the personal care worker, observation
by the RN; or a combination of these;
6. Be available for regular case conferences with the
Department of Health and Senior Services or its designee; and
7. Assist in orientation and personal care training for
personal care workers.
(I) If the supervisor is not an RN, the provider agency must
have a designated RN currently licensed in Missouri either on
staff or employed as a consultant.
(J) The RN’s responsibilities shall include to initial and review
all on-site visit reports made by the administrative supervisor.
If supervised by an RN, an LPN or Graduate Nurse (GN) may
perform the RN supervisory activities described in this section.
(K) An in-home personal care worker(s) shall meet the
following requirements:
1. Be at least eighteen (18) years of age;
2. Be able to read, write, and follow directions; and
3. May not be a family member of the participant for
whom personal care is to be provided. A family member is
defined as a spouse; parent; sibling; child by blood, adoption,
or marriage (step-child); grandparent; or grandchild.
(4) Reimbursement.
(A) Payment will be made in accordance with the fee per
unit of service as defined and determined by the MO HealthNet
Division.
1. A unit of service is fifteen (15) minutes.
2. Documentation for services delivered by the provider
must include the following:
A. The participant’s name and Medicaid number;
B. The date of service;
C. The time spent providing the service which must be
documented in one (1) of the following manners:
(I) When a personal care aide is providing services
to one (1) individual in a private home setting and devotes
undivided attention to the care required by that individual, the
actual clock time the aide began the services for that visit shall
be documented as the start time, and the actual clock time the
aide finished the care for the visit shall be documented as the
stop time per Electronic Visit Verification (EVV) regulation 13
CSR 70-3.320; and
(II) When the personal care services are provided in a
congregate living setting, such as RCFs I and II or ALFs, when
on-site supervision is available and personal care aide staff
will divide their time among a number of individuals, the
following must be documented: all tasks performed for each
participant by date of service and by staff shifts during each
twenty-four- (24-) hour period;
D. A description of the service; and
E. The name of the personal care aide who provided the
service.
3. A provider may not bill time spent in the delivery of
service of less than one (1) unit of service for any participant.
However, time spent in the delivery of service of less than one
(1) full unit for any participant may be accrued by the provider
to establish a unit of service. In no event may time spent in
the delivery of service be accrued beyond the last day of the
calendar month in which such services were rendered.
4. The fee per unit of service will be based on the
determination by the state agency of the reasonable cost of
providing the covered services on a statewide basis and within
the mandatory maximum payment limitations.
(B) Conditions for Reimbursement.
1. The personal care plan will be the authorization for
payment of service.
2. The total monthly payment for basic personal care
services made on behalf of an individual who requires basic
personal care only cannot exceed sixty percent (60%) of the
average statewide monthly cost for care in a nursing facility as
defined in 13 CSR 70-10.010(4)(Q) (excluding intermediate care
facilities for individuals with intellectual disabilities (ICFs/IID)).
3. The average monthly cost to the state for care in an NF
as defined in 13 CSR 70-10.010(4)(Q) (excluding ICFs/IID) will be
established in the month of May of each state fiscal year which
will become effective on July 1 of the following state fiscal year.
4. Payment will be made on the lower of the established
rate per service unit or the provider’s billed charges.
5. Rates will be established for personal care services in
private homes, licensed RCFs I and II, and ALFs.
(5) Advanced personal care services are maintenance services
provided to a participant in the participant’s home to assist
with activities of daily living when this assistance requires
devices and procedures related to altered body functions.
(A) Persons Eligible for Advanced Personal Care Services.
Any person who is determined eligible for Title XIX benefits
from the Family Support Division, found to be in need of
personal care services as an alternative to institutional care as
specified in section (1) of this rule, and who requires devices
and procedures related to altered body functions is eligible for
advanced personal care services.
(B) The following activities constitute advanced personal
care services and shall be provided according to the plan of
care:
1. Routine personal care of persons with ostomies
(including tracheostomies, gastrostomies, colostomies all with
well-healed stoma), which includes changing bags and soap
and water hygiene around ostomy site;
2. Personal care of persons with external, indwelling, and
suprapubic catheters, which include changing bags and soap
and water hygiene around site;
3. Removal of external catheters, inspect skin and reapply
catheter;
4. Administration of prescribed bowel programs, including
use of suppositories and sphincter stimulation per protocol and
enemas (prepacked only) without contraindicating rectal or
intestinal conditions;
5. Application of medicated (prescription) lotions,
ointments or dry, aseptic dressings to unbroken skin including
stage I decubitus;
6. Application of aseptic dressings to superficial skin
breaks or abrasions as directed by a licensed nurse;
7. Manual assistance with noninjectable medications as set
up by a licensed nurse;
8. Passive range of motion (nonresistive flexion of joint
within normal range) delivered in accordance with the care
plan; and
9. Use of assistive device for transfers.
(C) Instruction and encouragement to the participant in
ways to become more self-sufficient in advanced personal care
may be a component of all tasks as described above; however,
instruction and encouragement in and of themselves do not
constitute a task.
(D) Advanced Personal Care Plans. Plans of care which
include advanced personal care services must be developed by
the provider agency RN in collaboration with state agency staff
or its designee.
(E) Criteria for Providers of Advanced Personal Care Services.
Providers of advanced personal care must meet all criteria for
providers of personal care services described in section (3) of
this rule. Providers must sign an addendum to their Title XIX
Personal Care Provider Agreement and must possess a valid
contract with the Missouri Medicaid Audit and Compliance
Unit to provide Title XX services including advanced personal
care services. Residential care facilities wishing to provide
advanced personal care services to the eligible residents of
their own facility only may do so with a signed addendum to
their Title XIX Personal Care Provider Agreement.
1. All advanced personal care aides employed by the
provider must be an LPN or a certified nurse assistant, or a
competency-evaluated home health aide having completed
both written and demonstration portions of the test required by
the Missouri Department of Health and Senior Services and 42
CFR 484.80, or have successfully completed personal care aide
training. In addition, advanced personal care aides may not be
related to the participant to whom they provide personal care,
as defined in paragraph (3)(K)3. of this rule.
2. Personal care providers are required to provide training
to advanced personal care aides, in addition to the orientation
training described in section (3) of this rule. The additional
training shall consist of a minimum of six (6) hours and must
be completed prior to the provision of any advanced personal
care tasks. Providers may waive this six (6) hours of training if
one (1) of the following are met:
A. The proposed advanced personal care (APC) aide is
an LPN or CNA currently licensed or registered in the state of
Missouri; or
B. The proposed advanced personal care aide has
previously completed advanced personal care training from
a Medicaid or Social Services Block Grant (SSBG) in-home
provider agency, and that same personal care aide has been
employed by a Medicaid or SSBG in-home provider agency as
an advanced personal care aide within the prior six (6) months.
3. Advanced personal care aides employed by an RCF
II are exempt from the training requirements defined in
paragraphs (5)(E)1. and 2. of this rule if they have completed the
training requirements described in subdivisions (9) and (10) of
subsection 3 of section 198.073, RSMo, as amended.
4. The additional advanced personal care training must
include, at a minimum, the following topics:
A. Observation of the participant and reporting
observation;
B. Application of ointments/lotions to unbroken skin;
C. Manual assistance with oral medications;
D. Prevention of decubiti;
E. Bowel routines (rectal suppositories, sphincter
stimulation);
F. Enemas;
G. Personal care for persons with ostomies and catheters;
H. Proper cleaning of catheter bags;
I. Positioning and support of the participant;
J. Range of motion exercises;
K. Application of nonsterile dressings to superficial skin
breaks; and
L. Universal precaution procedures as defined by the
Centers for Disease Control and Prevention.
5. Advanced personal care tasks as specified at (5)(B)1.
through 9. shall not be assigned to or performed by any
advanced personal care aide who is not a licensed nurse until
the aide has been fully trained to perform the task, the RN,
LPN, or GN has personally observed successful execution of the
task and the RN, LPN, or GN has personally certified this in the
aide’s personnel record. An LPN or GN observing the execution
of a task must be trained in the APC tasks and observed by the
RN supervisor for successful completion of each task, and the
RN supervisor must personally certify this in the LPN’s or GN’s
personnel record. Only RN visits necessary for task observation
and certification in the home may be prior authorized and
billed to MO HealthNet Division as an authorized nurse visit,
as described in section (6) of this rule. RN task observation and
certification in a laboratory, or other non-home setting, may
not be billed.
6. The RN, LPN, or GN may observe the execution of any of
the tasks in a participant’s home or lab setting. However, it is
the responsibility of the provider to ensure the aide is properly
trained to execute tasks that may have variation from the lab
setting to the participant’s home setting.
7. For participants receiving advanced personal care
services, it is required that on-site RN visits be conducted at
intervals of no greater than six (6) months. During these visits,
the RN must conduct and document an evaluation of the
participant’s condition, continued eligibility for the program,
and the adequacy of the care plan. The RN must sign the
evaluation and the provider shall maintain documentation
of the evaluation in the participant’s record. The evaluation
must be produced upon request of the Division of Senior
and Disability Services or the Missouri Medicaid Audit and
Compliance Unit.
(F) Reimbursement.
1. Payment for advanced personal care services will be
made in accordance with the fee per unit of service as defined
and determined by the MO HealthNet Division. The fee per
unit (fifteen (15) minutes) of service will be based on the
determination of the state agency of the reasonable cost of
providing the covered services on a statewide basis and within
the mandatory maximum payment limitations.
2. Conditions for reimbursement.
A. An advanced personal care plan is required. It is to be
developed by the Department of Health and Senior Services or
its designee in cooperation with the provider agency’s RN. The
provider agency is responsible for obtaining the participant’s
physician’s approval for the plan.
B. The total monthly payment for advanced personal
care services as described in this section and for personal care
services as described in sections (1)–(7) of this rule made on
behalf of an individual cannot exceed one hundred percent
(100%) of the average statewide monthly cost for care in an NF
as defined in 13 CSR 70-10.010(4)(Q) (excluding ICFs/IID).
C. The average monthly cost to the state for care in an
NF, as defined in 13 CSR 70-10.010(4)(Q) (excluding ICF/IID), will
be established in the month of May of each state fiscal year,
which will become effective on July 1 of the following state
fiscal year.
D. Payment will be made on the lower of the established
rate per service unit or the provider’s billed charges.
3. Rates will be established for personal care services in
private homes, licensed RCFs I and II, and ALFs.
(6) Separately Authorized Nurses Visits.
(A) The provisions of paragraph (3)(H)3. notwithstanding,
reimbursement will be made for visits by nurse to particular
participants with special needs when the visits are prior
authorized by the Department of Health and Senior Services or
its designee. Providers of personal care services must have the
capacity to provide these authorized nurse visits in addition
to the nonauthorized nurse visits required by subsection (3)
(J). Anytime an authorized nurse visit is made, the nurse shall
also, in addition to other duties, evaluate the adequacy of the
plan of care, including a review of the plan of care with the
participant.
(B) To be eligible to receive the authorized nurse visit, the
participant must—
1. Be determined eligible for Title XIX benefits from the
Family Support Division and found to be in need of personal
care services as an alternative to institutional care as specified
in section (1) of this rule;
2. Have no other person available who could and would
provide the services;
3. Require one (1) or more of the services described in
subsection (6)(D) as an alternative to institutionalized care; and
4. Meet any additional criteria of need set forth in
subsection (6)(D).
(C) The services provided during the authorized nurse visit
shall not include any service which the participant would
be eligible to receive under either the Medicare (Title XVIII)
or Medicaid (Title XIX) Home Health programs. The services
listed in subsection (6)(D) do not qualify, by themselves, for
reimbursement under either program. However, should a
participant otherwise be eligible for home health services,
then those services listed in paragraphs (6)(D)1.–4. will be
provided by the home health agency and not under the
Personal Care Program.
(D) The services of the nurse shall provide increased
supervision of the aide, assessment of the participant’s health,
and the suitability of the care plan to meet the participant’s
needs. These services also shall include any referral or follow-up
action indicated by the nurse’s assessment. These services, in
addition, must include one (1) or more of the following where
appropriate to the needs of the participant and authorized by
the Department of Health and Senior Services or its designee:
1. The RN may fill insulin syringes in advance per
manufacturer’s instructions for participants with diabetes who
can self-inject the medication but cannot fill their own syringe.
This service would include monitoring the participant’s
continued ability to self-administer the insulin;
2. The RN may set up oral medications in divided
daily compartments for a participant who self-administers
prescribed medications but needs assistance and monitoring
due to a minimal level of disorientation or confusion;
3. The RN may monitor a participant’s skin condition when
a participant is at risk of skin breakdown due to immobility,
incontinency, or both;
4. The RN may provide nail care for a participant with
diabetes or other medically contraindicating conditions if the
participant is unable to perform this task;
5. The RN will be authorized to visit all personal care
participants who also receive advanced personal care as
described in section (4) of this rule, on a monthly basis, to
evaluate the adequacy of the authorized services to meet
the needs and conditions of the participant and to assess
the advanced personal care aide’s ability to carry out the
authorized services;
6. The RN may provide on-the-job training to advanced
personal care aides as described in paragraph (5)(E)6. of this
rule;
7. The visits authorized under section (6) may be carried
out by an LPN or GN, if under the direction of an RN; or
8. The RN may be authorized to provide other services
in other situations, subject to the conditions set forth in
subsection (6)(C).
(E) Payment for the authorized nurse visit will be made in
accordance with the fee per unit of service as defined and
determined by the MO HealthNet Division.
1. A unit of service is the visit. No minimum or maximum
time is required to constitute a visit.
2. The maximum number of units which a participant can
receive is twenty-six (26) within a six- (6-) month period of time.
The cost of the nurse visits are not included in the spending
cap set forth in paragraph (4)(B)2. but must be included in the
spending cap specified at subparagraph (5)(F)2.B.
(F) Documentation of the authorized nurse visit shall include
written notes and observations. These will be maintained
in the participant’s file. In addition, notes of any verbal
communication and copies of any written communications
with the participant’s physician or other health care professional
concerning the care of that participant also will be maintained
in the participant’s file.
AUTHORITY: section 208.152, RSMo Supp. 2022, and sections
208.153 and 208.159, RSMo 2016.* This rule was previously filed
as 13 CSR 40-81.125. Original rule filed April 14, 1982, effective
July 11, 1982. Amended: Filed May 13, 1983, effective Aug. 11, 1983.
Amended: Filed May 11, 1984, effective Aug. 11, 1984. Emergency
amendment filed June 25, 1986, effective July 5, 1986, expired
Nov. 2, 1986. Amended: Filed July 25, 1986, effective Oct. 11, 1986.
Emergency amendment filed Sept. 1, 1989, effective Sept. 11, 1989,
expired Jan. 7, 1990. Amended: Filed Oct. 3, 1989, effective Dec.
28, 1989. Emergency amendment filed July 31, 1992, effective Aug.
10, 1992, expired Dec. 7, 1992. Emergency amendment filed Nov.
25, 1992, effective Dec. 8, 1992, expired April 6, 1993. Amended:
Filed July 31, 1992, effective April 8, 1993. Emergency amendment
filed June 18, 1993, effective July 1, 1993, expired Oct. 28, 1993.
Emergency amendment filed Sept. 2, 1993, effective Oct. 1, 1993,
expired Jan. 28, 1994. Emergency amendment filed Feb. 2, 1994,
effective Feb. 12, 1994, expired June 11, 1994. Amended: Filed Sept.
2, 1993, effective April 9, 1994. Emergency amendment filed April
4, 1994, effective May 1, 1994, expired Aug. 28, 1994. Amended:
Filed April 4, 1994, effective Oct. 30, 1994. Emergency amendment
filed Oct. 14, 1994, effective Oct. 24, 1995, expired Feb. 20, 1995.
Emergency amendment filed March 31, 1995, effective April 13,
1995, expired Aug. 10, 1995. Amended: Filed Oct. 21, 1994, effective
June 30, 1995. Amended: Filed Aug. 1, 1996, effective March
30, 1997. Amended: Filed Aug. 29, 1997, effective April 30, 1998.
Amended: Filed Dec. 15, 1997, effective July 30, 1998. Amended:
Filed Dec. 15, 2000, effective June 30, 2001. Amended: Filed Jan.
15, 2004, effective Aug. 30, 2004. Amended: Filed April 29, 2005,
effective Oct. 30, 2005. ** Amended: Filed Feb. 6, 2023, effective
Aug. 30, 2023.
*Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977,
1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, 2013, 2014, 2015, 2016,
2018, 2021; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012; and
208.159, RSMo 1979.
**Pursuant to Executive Order 21-07, 13 CSR 70-91.010, paragraph (1)(B)3. and subparagraph (1)
(C)1.F. was suspended from April 30, 2020 through May 1, 2021. Pursuant to Executive Order 21-09,
13 CSR 70-91.010, paragraph (1)(B)1., subsections (3)(E) and (3)(G), paragraphs (3)(H)2., (3)(H)3.,
(3)(J)1., (3)(K)3., and (3)(K)4., subparagraph (4)(A)2.F., paragraphs (4)(B)1.-2., subparagraphs (5)
(F)2.A.-B., and subsection (5)(E) was suspended from April 30, 2020 through December 31, 2021.