210-RICR-50-10-2
210-RICR-50-10-2. Self-Directed Care (version Amendment, 12/15/2020 to 01/04/2022)
2.1 Purpose
These Rules apply to two (2)
consumer self-directed programs and the services provided by Personal
Care Aides (PCA) under these programs. These Rules set out the
eligibility criteria and program operation for two (2) self-directed
care programs, the Personal Choice Program (PCP) and the Independent
Provider (IP) Program, both of which allow consumers to have
responsibility for managing their long-term services and supports in
a person-centered manner. Consumers choose who provides the services
and how they are provided. Self-directed services are intended to
support community tenure and consumer independence.
2.2 Applicability
A. Program Descriptions
1. The Personal Choice Program
(PCP) provides consumer-directed home and community-based services to
Medicaid long-term services and supports (LTSS) eligible consumers.
Personal Choice is a long-term care service for individuals with
disabilities who are over the age of eighteen (18) or elders aged
sixty-five (65) or over who meet either a high or highest level of
care. Services are geared toward reducing unnecessary
institutionalization by providing specialized home and
community-bases services to qualified Medicaid consumers at an
aggregate cost which is less than or equal to the cost of
institutional or nursing facility care.
2. Independent Provider Model
(IP) – The IP is a self-directed pathway available to all adult
LTSS consumers choosing services in an at-home setting who are
seeking to self-direct only nonmedical personal care and homemaker
services for individuals with disabilities who are over the age of
eighteen (18) or elders aged sixty-five (65) or over who meet either
a high or highest level of care. The LTSS consumer has the
flexibility to select a trained PCA of choice and self-direct the
schedule and way the IP authorized services are provided by the PCA.
B. These Regulations do not
apply to Intellectual and Developmental Disabilities (I/DD)
Self-Directed programs funded by the Rhode Island Department of
Behavioral Healthcare, Developmental Disabilities and Hospitals
(BHDDH) pursuant to R.I. Gen. Laws § 40.1-1-13. To reference the
BHDDH Regulations for Self-Directed services, please refer to the
Rules and Regulations for Developmental Disability Organization
212-RICR-10-05-1.10.3 ,
Fiscal Intermediary Services and 212-RICR-10-05-1.2(A)(42) ,
Definitions.
C. Pursuant to R.I. Gen. Laws
§ 40-8.15-2(b) ,
nothing in this Part shall interfere with the regulatory authority of
the Rhode Island Department of Health (RIDOH) over individual
providers’ licensing.
2.3 Authority
Title XIX of the Social
Security Act, 42 U.S.C. §§ 1396-1396v, provides the legal
authority for the Rhode Island Medicaid Program. The Medicaid Program
also operates under a waiver granted by the Secretary of Health and
Human Services pursuant to § 1115 of the Social Security Act.
Additionally, R.I. Gen. Laws Chapters 40-6, 40-8, 40-18, 40-8.14, and
40-8.15 serve as the enabling statutes for the Independent Provider
and Personal Choice Programs.
2.4 Definitions
A. The following terms, which
are listed alphabetically, are referenced in this Regulation.
1. "Activities of daily
living skills" or "ADLs" means everyday routines
generally involving functional mobility and personal care, including
but not limited to, bathing, dressing, eating, toileting, mobility
and transfer.
2. “Applicant”
means new applicants to be determined for Medicaid eligibility.
3. “Case management
services” means the coordination of a plan of care and services
provided at home to individuals with disabilities who are over the
age of eighteen (18) or elders aged sixty-five (65) or over who meet
either a high or highest level of care. Such programs shall be
provided in the person’s home or in the home of a responsible
relative or other responsible adult, but not provided in a skilled
nursing facility and/or an intermediate care facility.
4. “Consumer”
means the individual, also referred to as the beneficiary or
participant, who utilizes services in any of the self-directed
models.
5. “Critical incident”
means any actual or alleged event or situation that creates a
significant risk of substantial or serious harm to the physical or
mental health, safety or well-being of a participant.
6. “Environmental
modifications” are defined as those physical adaptations to the
home of the participant or the participant’s family as required
by the participant’s service plan, that are necessary to ensure
the health, welfare and safety of the participant or that enable the
participant to attain or retain capability for independence or
self-care in the home and to avoid institutionalization, and are not
covered or available under any other funding source. A completed home
assessment by a specially trained and certified rehabilitation
professional is also required. Such adaptations may include the
installation of modular ramps, grab-bars, vertical platform lifts and
interior stair lifts. Excluded are those adaptations that are of
general utility, are not of direct medical or remedial benefit to the
participant. Excluded are any re-modeling, construction, or
structural changes to the home, i.e. (changes in load bearing walls
or structures) that would require a structural engineer, architect
and/or certification by a building inspector.
a. Adaptations that add to the
total square footage of the home are excluded from this benefit. All
adaptations shall be provided in accordance with applicable state or
local building codes, and prior approval on an individual basis by
EOHHS, Office of Durable Medical Equipment, is required.
b. Items should be of a nature
that they are transferable if a participant moves from his/her place
of residence.
7. “Fiscal intermediary
services (FI) for the Personal Choice Program” means services
that are designed to assist participants in allocating funds as
outlined in the Individual Service and Spending Plan and to
facilitate employment of personal assistance staff by the
participant.
8. “Fiscal intermediary
services (FI) for the Independent Provider Program” means
services that are designed to assist participants in utilizing hours
as outlined in the Individual Service Plan and to facilitate
employment of personal assistance staff by the participant. The FI
also functions as the agency to assist in the management of financial
and employer responsibilities.
9. “Home delivered
meals” means the delivery of hot meals and shelf staples to the
participant’s residence. Meals are available to individuals
unable to care for their nutritional needs because of a functional
dependency/disability and who require this assistance to live in the
community. Meals provided under this service will not constitute a
full daily nutritional requirement. Meals must provide a minimum of
one third (1/3) of the current recommended dietary allowance.
Provision of home delivered meals will result in less assistance
being authorized for meal preparation for individual participants, if
applicable.
10. “Individual service
plan” or “ISP” means a plan that provides details
of supports, activities, and resources required for the consumer to
achieve personal goals. The Individual Service Plan (ISP) is
developed to articulate decisions and agreements made during a
person-centered process of planning and informational gathering.
11. “Individual service
and spending plan” or “ISSP” means a plan that
shows the service that are purchased with the budget provided through
the Personal Choice Program. The plan shows the services purchased,
the rate purchased at and the total dollars spent on care. ISSP
provides information on the consumer’s goods and services, as
well as taxes and fees associated with their budget. This plan can be
updated annually or as the budget changes.
12. “Instrumental
activities of daily living” or “IADL” means
activities related to living independently in the community,
including but not limited to, meal planning and preparation, managing
finances, shopping for food, clothing, and other essential items,
performing essential household chores, communicating by phone or
other media, and traveling around and participating in the community.
13. “Mandatory
orientations” means training required by EOHHS for all PCAs
participating in the IP program. Mandatory Orientations include
program overview and structure, policy and procedure explanation,
review of ethics, accountability, HIPAA and Electronic Visit
Verification (EVV), coverage of abuse and neglect, IP PCA scope of
work and excluded duties, infection control and safety.
14. “Medical necessity”
or “Medically necessary services” means medical,
surgical, or other services required for the prevention, diagnosis,
cure or treatment of a health-related condition including services
necessary to prevent a detrimental change in either medical or mental
health status.
15. “Minor environmental
modifications” means minor modifications to the home that may
include grab bars, versa frame (toilet safety frame), handheld shower
and/or diverter valve, raised toilet seats and other simple devises
or appliances such as eating utensils, transfer bath bench, shower
chair, aides for personal care and standing poles to improve home
accessibility adaptation, health or safety.
16. “Nonmedical”
means not involving, relating to, used in, or concerned with medical
care or the field of medicine.
17. “Participant
directed goods and services” means services, equipment or
supplies not otherwise provided through Medicare or Medicaid, that
address an identified need and are in the approved ISP (including
improving and maintaining the individual’s opportunities for
full membership in the community) and meet the following
requirements: the item or service would decrease the need for other
Medicaid services; AND/OR promote inclusion in the community; AND/OR
the item or service would increase the individual’s ability to
perform ADLs or IADLs; AND/OR increase the person’s safety in
the home environment; AND, alternative funding sources are not
available. Individual goods and services are purchased from the
individual’s self-directed budget through the fiscal
intermediary when approved as part of the ISP. Examples include a
laundry service for a person unable to launder and fold clothes or a
microwave for a person unable to use a stove due to his/her
disability. This will not include any good/service that would be
restrictive to the individual or strictly experimental in nature.
18. “Personal care
aide(s) services” means the provision of direct support
services provided in the home or community to individuals in
performing tasks they are functionally unable to complete
independently due to disability, based on the Individual Service and
Spending Plan, or the ISP. Personal Care Aide(s) Services may include
but are not limited to:
a. Participant assistance with
activities of daily living, such as grooming, personal hygiene,
toileting, bathing, and dressing;
b. Assistance with monitoring
health status and physical condition;
c. Assistance with preparation
and eating of meals (not the cost of the meals itself);
d. Assistance with
housekeeping activities (bed making, dusting, vacuuming, laundry,
grocery shopping, cleaning);
e. Assistance with
transferring, ambulation; use of special mobility devices; assisting
the participant by directly providing or arranging transportation. If
providing transportation in the Personal Choice Program and the
Independent Provider Program, the PCA must have a valid driver’s
license and liability coverage as verified by the FI.
19. “Personal emergency
response” or “PERS” means an electronic device that
enables certain individuals at high risk of institutionalization to
secure help in an emergency. The individual may also wear a portable
“help” button to allow for mobility. The system is
connected to the person’s phone and programmed to signal a
response center once a “help” button is activated. This
service includes coverage for installation and a monthly service fee.
Providers are responsible to ensure the upkeep and maintenance of the
devices/systems.
20. “Registry”
means the official list, maintained by EOHHS or its designee, of
qualified PCAs who are available to provide services. Consumers may
utilize the registry when hiring PCAs through the IP program.
21. “Self-directed”
means a consumer-controlled method of selecting and providing
services and supports that allows the individual maximum control of
the home and community-based aid services and supports, with the
individual acting as the employer of record with necessary supports
to perform that function, or the individual having a significant and
meaningful role in the management of a provider of service when the
agency-provider model is utilized. Individuals exercise as much
control as desired to select, train, supervise, schedule, determine
duties, and dismiss the aid care provider.
22. “Service advisory
agency” or “SA” means an agency that will assess
service needs, assist with planning what services are needed and how
to receive them, be an additional resource to the consumer,
representative, and/or family to promote safety and quality of care.
23. “Service advisement
team” means a team, consisting of the Service Advisor, a Nurse
and a Mobility Specialist, that will focus on empowering participants
to define and direct their own personal assistance needs and
services.
24. “Special medical
equipment” or “Minor assistive devices” means the
following:
a. Devices, controls, or
appliances, specified in the plan of care, which enable participants
to increase their ability to perform activities of daily living;
b. Devices, controls, or
appliances that enable the participant to perceive, control, or
communicate with the environment in which they live; including such
other durable and non-durable medical equipment not available through
the participant's medical insurance that is necessary to address
participant functional limitations;
c. Items reimbursed with
waiver funds through the Personal Choice Program are in addition to
any medical equipment and supplies furnished by Medicaid and exclude
those items that are not of direct medical or remedial benefit to the
participant. All items shall meet applicable standards of
manufacture, design and installation. Provision of Specialized
Medical Equipment requires prior approval on an individual basis by
Medicaid.
25. “Supports for
consumer direction” or “Supports facilitation”
means empowering participants to define and direct their own personal
assistance needs and services, guides and supports, rather than
directs and manages, the participant through the service planning and
delivery process.
2.5 Eligibility
A. All general eligibility
Rules for Medicaid LTSS contained in the Rhode Island Code of
Regulations, Subchapter
00 Part 1 of this Chapter , Medicaid LTSS Overview and
Eligibility Pathways, and Subchapter
00 Part 4 of this Chapter , Long-Term Services and
Supports Application and Renewal Process, apply to the Self-Directed
Programs. Additional eligibility requirements for Self-Directed
Programs are as follows:
1. Consumers who are either
aged (age sixty-five (65) and older) or who have a disability and are
at least eighteen (18) years old and are determined to have high or
highest need for level of care and;
2. Individuals who have
demonstrated the ability and competence to direct their own care or
have a qualified designated representative to direct care, and want
to either remain in their home or return to their home;
3. Individuals who have been
determined to be Developmentally Disabled and are receiving services
via the Department of Behavioral Healthcare, Developmental
Disabilities, and Hospitals (BHDDH) and are interested in the
Personal Choice Program or Independent Provider program must be
approved by BHDDH and EOHHS Medicaid.
B. Income
All income eligibility Rules
contained in Subchapter
00 Part 6 of this Chapter , Medicaid Long-Term Services
and Supports: Financial Eligibility, and as amended from time to
time, apply. If Medically Needy eligible, the applied income cannot
exceed the cost of services.
C. Resources
All resource Rules contained
in Subchapter
00 Part 6 of this Chapter , Medicaid Long-Term Services and
Supports: Financial Eligibility, and as amended from time
to time, apply.
D. Post Eligibility Treatment
of Income
Information relating to Post
Eligibility Treatment of Income (PETI) can be found in Subchapter
00 Part 8 of this Chapter , Post-Eligibility Treatment
of Income.
2.6 Enrollment and Disenrollment
A. Enrollment
Enrollment in all
Self-Directed programs is by choice. Individuals who wish to
participate and who meet all the eligibility requirements may contact
a Service Advisement Agency, a Fiscal Intermediary, or visit the
EOHHS website http://www.eohhs.ri.gov/.
B. Involuntary Disenrollment
1. When a Medicaid-eligible
participant is involuntarily disenrolled from a Self-Directed
Program, the participant is referred to EOHHS or BHDDH to explore
other available options.
2. EOHHS shall notify the
participant in writing that they intend to remove the participant
from their Self-Directed Program, the reason for disenrollment, and
shall inform the participant that services will be provided through
Medicaid long-term care via a home health agency.
3. The participant shall be
involuntarily disenrolled from the Self-Directed Program if he/she
loses either Medicaid financial eligibility or level of care
eligibility.
4. Disenrollment is determined
by the Service Advisement Agency, and confirmed by EOHHS, based on an
assessment in conjunction with the policies and procedures of that
Agency, and/or the receipt of information from the Fiscal
Intermediary or EOHHS. Involuntary disenrollment may also occur when:
a. Participant or
representative is unable to self-direct purchase and payment of LTSS.
b. A representative proves
incapable of acting in the best interest of the participant, can no
longer assist participant, and no replacement is available.
c. Participant or
representative fails to comply with legal/financial obligations as an
“employer” of domestic workers and/or is unwilling to
participate in advisement training or training to remedy
non-compliance.
d. If enrolled in Personal
Choice, the participant or representative is unable to manage the
monthly spending as evidenced by: repeatedly submitting time sheets
for unauthorized budgeted amount of care; underutilizing the monthly
budget, which results in inadequate services; and/or continuing
attempts to spend budget funds on non-allowable items and services.
e. If enrolled in IP, the
participant or representative is unable to manage the hours to be
services as evidenced by: repeatedly submitting time sheets for
unauthorized amount of care; underutilizing the hours allocated,
which results in inadequate services; and/or continuing attempts add
more hours than allocated.
f. Participant’s health
and well-being is not maintained through the actions and/or inactions
of the participant or representative.
g. Participant or
representative fails to maintain a safe working environment for
personal care.
h. EOHHS receives a complaint
of participant self-neglect, neglect, or other abuse.
i. Either the participant or
representative refuses to cooperate with minimum program oversight
activities, even when staff has made efforts to accommodate the
participant.
j. Participant or
representative fails to pay the amount determined in the post
eligibility treatment of income, as described Subchapter
00 Part 8 of this Chapter , Post-Eligibility Treatment
of Income, to the fiscal agency.
k. There is evidence that
Medicaid funds were used improperly/illegally according to local,
State or Federal Regulations.
l. The Service Advisement
Agency determines they are unable to provide proper service. Proper
service is defined as the agency not being able to meet repeated
requests for services, being unable to satisfy consumer needs, and/or
provide an individual with a quality working relationship.
m. Participant or
representative fails to notify both the Service Advisement Agency and
the Fiscal Intermediary of any change of address and/or telephone
number within ten (10) days of the change.
C. Voluntary Disenrollment
1. Participant or
representative may request discharge from a Self-Directed Program
with a thirty (30) day written notice to the Service Advisement
Agency and Fiscal Intermediary.
2. A participant’s
representative must provide both the Service Advisement Agency and
Fiscal Intermediary with a thirty (30) day written notice stating
they are no longer able to provide representative services.
D. Disenrollment Appeal
1. The Service Advisement
Agency and the Fiscal Intermediary Agency shall inform the
participant in writing of an involuntary disenrollment with the
reason and provides the participant with a Medicaid appeal procedure
and request forms.
2. The PCP participant has the
right to appeal utilizing the standard appeals process as described
in Part
10-05-2 of this Title , Appeals Process and Procedures
for EOHHS Agencies and Programs.
2.7 Appeals
An opportunity for a hearing
is granted to an applicant/recipient or his/her designated
representative, when a person is aggrieved by an agency action
resulting in a disenrollment, suspension, reduction, discontinuance,
or termination of a consumer’s services or budget, or a
requested adjustment to the budget or service is denied in accordance
with the provisions of Part
10-05-2 of this Title , Appeals Process and Procedures
for EOHHS Agencies and Programs.
2.8 Background Check Requirements
for PCAs
A. All Personal Care Aides and
consumer representatives that have direct contact with consumers must
submit to a National and a Rhode Island Bureau of Criminal
Identification (BCI) screening, Office of Inspector General (OIG)
screenings, and an Abuse Registry Record Check annually to be
authorized to provide assistance to consumers under the Self-Directed
programs. To participate in the Self-Directed programs as the
consumer’s representative or in a provider (PCA) capacity,
there must be no evidence of disqualifying criminal convictions as
cited in the following manuals available through the EOHHS or
obtained on its website (www.eohhs.ri.gov). The listed manuals
include standards and procedures on National and Rhode Island
Criminal Identification screenings:
1. Personal Choice Participant
Manual,
2. Personal Choice
Representative Manual,
3. IP Participant Manual, or
4. IP Provider Manual.
2.9 Personal Choice Program
2.9.1 Eligibility
A. Consumers who are either
aged (age sixty-five (65) or over) or who have a disability and are
at least eighteen (18) years old and are determined to have high or
highest need for level of care and;
B. Individuals who have
demonstrated the ability and competence to direct their own care or
have a qualified designated representative to direct care, and want
to either remain in their home or return to their home.
2.9.2 Assessments
A. Minimum assessment
components will be specified by EOHHS and be maintained in both the
Personal Choice Participant/Representative Manual and Provider Manual
available through EOHHS or obtained on its website: www.eohhs.ri.gov.
B. Nursing Assessment –
The Nursing Assessment is one (1) of the multiple assessments done
for the individual. This assessment measures Activities of Daily
Living (ADLS) and Instrumental Activities of Daily Living (IADLS)
which are conducted to determine participant needs and goals. A
nursing assessment must be performed by a nurse licensed by RIDOH in
accordance with 216-RICR-40-05-3 ,
Licensing of Nurses and Standards for the Approval of
Basic Nursing Education Programs.
C. Functional Assessment –
The functional assessment rates the participant’s level of
assistance required to complete each task, and the number of times
the task is performed. If there is a condition or characteristic in
addition to the disability, the participant may require the need for
more time to complete a particular task. These conditions and/or
characteristics do not apply to all ADL/IADL tasks; they only apply
if the condition would have a direct impact on the performance of the
task.
1. In addition to medical
information and self-reporting, the assessor may observe or request
that the participant demonstrate his/her ability to complete a task.
2. When a participant is
identified through the Nursing Home Transition Program/Money Follows
the Person Program, a temporary assessment shall be conducted. This
shall be a temporary assessment because it is conducted while the
participant is in an institutional Nursing Home setting and may not
fully reflect the participant’s functional abilities within a
non-institutional home setting. The Service Advisement Agency
selected by the participant consumer shall complete an updated
assessment within ninety (90) days of the participant returning home.
After the temporary assessment is completed the Office of Community
Programs staff shall review the assessment with the participant to:
a. Verify that the participant
wants to participate in the Personal Choice program; and
b. Identify
the participant’s choice of Service Advisement Agency
responsible for the additional assessments and oversight of the
participant’s program. The participant will have appeals rights
as outline in Part 10-05-2
of this Title, Appeals Process and Procedures for EOHHS Agencies and
Programs.
D. In addition to the nursing
and functional assessments, staff will conduct an environmental
assessment and a Universal Comprehensive Assessment Tool (UCAT)
assessment as part of the eligibility determination and plan of care.
2.9.3 Budget Development
A. Personal Choice monthly
budgets are based on the functional assessment of participant need
for hands-on assistance or supervision with ADL’s (such as
bathing, toileting, dressing, grooming, transfers, mobility,
skincare, and/or eating) and IADL’s (such as communication,
shopping, housework, meal preparation, and/or food shopping), as
described in § 2.9.2 of this Part.
B. The Service Advisement
Agency will perform assessments to determine the individual’s
budget and Individual Service and Spending Plan (ISSP). In accordance
with the service provider agreements, a budget is developed based on
the amount and level of assistance required, frequency of the task,
and presence of any secondary conditions that would require a need
for more time to complete the task. There are six (6) levels of
assistance for each activity.
1. Determine Monthly Budget
Amount: Each Activity of Daily Living (ADL) and Instrumental Activity
of Daily Living (IADL) has an amount of unit and/or functional time
allowed to complete the task. The monthly figures for each ADL/IADL
are added together to form a monthly budget. Worker’s
compensation insurance and administrative costs are deducted from the
PCP participant’s monthly budget.
a. Unit Time – the
amount of time allowed to complete the task if the participant is
unable to participate and requires total assistance with the task.
b. Functional Time – the
amount of time allowed to complete the task if the participant is
unable to participate and requires total assistance with the task and
certain conditions or characteristics are present.
2. EOHHS will implement a
budget re-assessment for any budget which is decreased by five
hundred dollars ($500.00). This second (2 nd ) level
re-assessment will be conducted by an EOHHS nurse and social worker
in the home of the consumer.
3. Written documentation of
the assessment will be maintained by the Service Advisement Agency,
such as the functional, mobility and health assessments.
4. Additional information
concerning participant conditions and characteristics related to
certain tasks may be found in the Participant Manual and/or the
Provider Manual, available upon request or on the Medicaid website,
http://www.eohhs.ri.gov/ .
C. The budget amount is
determined by EOHHS and may be subject to change. The budget funds
are set aside by Medicaid for the purchase of assistance to meet
individual participant needs. The participant determines what
services are required and the amount the participant is willing to
pay for those services from their budget. Participants determine the
hourly wage for PCA, which can range from minimum wage up to fifteen
dollars ($15.00) per hour. The budget does not allow for
companionship, watching, or general supervision of a participant.
D. The service advisor will
provide the participant/representative with a copy of the approved
budget and the approved ISSP. Additional copies may be provided upon
request.
E. The Service Advisory Agency
will provide the Personal Choice fiscal intermediary with a copy of
the approved budget.
2.9.4 Participant Directed
Goods and Services
A. Participants may also set
aside a specified amount of their budget each month to purchase
services, equipment and supplies not otherwise provided by Medicaid
that address an identified need, are in the approved ISSP, and meet
the following requirements:
1. Alternative funding sources
are not available; and
2. The item or service would
decrease the need for other Medicaid services; and/or
3. The item or service would
promote inclusion in the community; and/or
4. The item or service would
increase the individual’s ability to perform ADLs/IADLs; and/or
5. The item or service would
increase the person’s safety in the home environment.
B. Limitations:
1. Some items or services that
are medical in nature may be reimbursed with a health care
practitioner’s order.
2. Items must be necessary to
ensure the health, welfare and safety of the participant, or must
enable the participant to function with greater independence in the
home or community, and to avoid institutionalization.
3. Items for entertainment
purposes are not covered.
4. Items cannot duplicate
equipment provided under Medicaid-funded primary and acute care or
through other sources of funding, such as Medicare or private
insurance.
5. Items purchased whose goal
is to lessen the need for assistance from a caregiver will result in
a redetermination of need for caregiver assistance.
C. Additional information for
the participant can be found in the PCP Participant Guide, located on
the Medicaid website, http://www.eohhs.ri.gov/.
2.9.5 EOHHS
Responsibilities
A. EOHHS shall be responsible
for the following activities:
1. Approve budgets and
individual service and spending plans;
2. Authorization of
participant-directed goods and services;
3. Provide Personal Choice
participants with notice of budget amount;
4. Monitor and conduct
quarterly audits of service advisement and fiscal intermediary
agencies.
B. The EOHHS reviews and
approves the assessment and individual service and spending plan
(ISSP) for each PCP participant before services begin.
C. Any changes made to a PCP
participant’s ISSP must be forwarded to EOHHS for review and
approval.
D. Once the ISSP is approved,
EOHHS will notify the appropriate Service Advisement Agency who will
inform the Fiscal Agency and participant that the ISSP will be
implemented.
E. EOHHS is responsible for
the review of reported critical incidents with the Service Advisement
Agency to determine feasibility of the individual continuing
participation in the Personal Choice Program.
F. If Medicaid fraud is either
known or suspected, EOHHS shall refer the case to the appropriate
authorities as outlined in the Medicaid Personal Choice Program
Provider Manual, http://www.eohhs.ri.gov/ .
2.10 Independent Provider
2.10.1 Eligibility
A. Consumers who are either
aged (age sixty-five (65) or over) or who have a disability and are
at least eighteen (18) years old and are determined to have high or
highest need for level of care and;
B. Individuals who have
demonstrated the ability and competence to direct their own care or
have a qualified designated representative to direct care, and want
to either remain in their home or return to their home.
2.10.2 Assessments
A. Minimum assessment
components will be specified by EOHHS and be maintained in both the
Independent Provider Participant/Representative Manual and Provider
Manual available through EOHHS or obtained on its website,
www.eohhs.ri.gov .
B. Nursing Assessment –
An assessment measuring Activities of Daily Living (ADLS) and
Instrumental Activities of Daily Living (IADLS) is conducted to
determine participant needs and goals.
C. Functional Assessment –
The functional assessment rates the participant’s level of
assistance required to complete each task, and the number of times
the task is performed. If there is a condition or characteristic in
addition to the disability, the participant may require the need for
more time to complete a particular task. These conditions and/or
characteristics do not apply to all ADL/IADL tasks; they only apply
if the condition would have a direct impact on the performance of the
task.
1. In addition to medical
information and self-reporting, the assessor may observe or request
that the participant demonstrate his/her ability to complete a task.
2. When a participant is
identified through the Nursing Home Transition Program/Money Follows
the Person Program, a temporary assessment shall be conducted. This
shall be a temporary assessment because it is conducted while the
participant is in an institutional Nursing Home setting and may not
fully reflect the participant’s functional abilities within a
non-institutional home setting. The Service Advisement Agency
selected by the participant consumer shall complete an updated
assessment within ninety (90) days of the participant returning home.
After the temporary assessment is completed the Office of Community
Programs staff shall review the assessment with the participant to:
a. Verify that the participant
wants to participate in the Personal Choice program; and
b. Identify
the participant’s choice of Service Advisement Agency
responsible for the additional assessments and oversight of the
participant’s program. The participant will have appeals rights
as outline in Part 10-05-2
of this Title , Appeals Process and Procedures for EOHHS
Agencies and Programs .
D. In addition to the nursing
and functional assessments, staff will conduct an environmental
assessment and a Universal Comprehensive Assessment Tool (UCAT) as
part of the eligibility determination and plan of care.
2.10.3 Service Hours
A. Independent Provider
service hours are determined based on the functional assessment of
participant need for hands-on assistance or supervision with ADL’s
(such as bathing, toileting, dressing, grooming, transfers, mobility,
skincare, and/or eating) and IADL’s (such as communication,
shopping, housework, meal preparation, and/or food shopping), as
described in § 2.4 of this Part.
B. The Service Advisement
Agency will perform assessments to determine the individual’s
service hours and ISP. In accordance with the service provider
agreements, service hours are authorized based on the amount and
level of assistance required, frequency of the task, and presence of
any secondary conditions that would require a need for more time to
complete the task.
1. EOHHS will implement a
re-assessment for any service plan in which the number of hours is
reduced or increased significantly with no corresponding
documentation of a significant medical change or significant life
event in the individual’s assessment. This second (2 nd )
level re-assessment will be conducted by an EOHHS nurse and social
worker in the home of the consumer.
2. Written documentation of
the assessment and ISP will be maintained by the Service Advisement
Agency.
3. Additional information
concerning participant conditions and characteristics related to
certain tasks may be found in the Participant Manual and/or the
Provider Manual, available upon request or on the Medicaid website,
http://www.eohhs.ri.gov/ .
C. The hours authorized in the
service plan are determined by EOHHS and may be subject to change.
Service hours do not allow for companionship, watching, or general
supervision of a participant.
D. The Service Advisor will
provide the participant/representative with a copy of the approved
budget and the approved ISP. Additional copies may be provided upon
request.
E. The Service Advisory Agency
will provide the Independent Provider Fiscal Intermediary with a copy
of the approved budget.
F. Once approved the consumer
can utilize those hours for non-medical personal care and homemaker
services. There is no allowance for differential pay to the PCA for
hours worked beyond forty (40) hours (where applicable) or on
Saturdays, Sundays, Holidays, or off-hours.
2.10.4 EOHHS
Responsibilities
A. EOHHS shall be responsible
for the following activities:
1. Approve service hours and
ISPs;
2. Provide Independent
Provider participants with notice of ISP and authorized service
hours;
3. Monitor and conduct
quarterly audits of Service Advisement and Fiscal Intermediary
agencies.
B. The EOHHS reviews and
approves the assessment and ISP for each IP participant before
services begin.
C. Any changes made to a
participant’s ISP must be forwarded to EOHHS for review and
approval.
D. Once the ISP is approved,
EOHHS will notify the appropriate Service Advisement Agency who will
inform the Fiscal Agency and participant that the service plan will
be implemented.
E. EOHHS is responsible for
establishing rates for PCA services. EOHHS will oversee PCA training
modules and will establish terms and conditions of the workforce
without infringing on rights of the consumer to hire, direct,
supervise, or terminate.
1. If a
prospective PCA is a family member or friend, with the written
permission of the consumer, the PCA may begin providing services and
receiving payment for such services after signing an attestation that
they will complete the mandatory orientation within thirty (30) days
of commencing employment as a PCA. The PCA shall also attest to
completing background checks in accordance with § 2.8 of this
Part within fourteen (14) days of the start of employment and CPR
training within ninety (90) days of the start of employment. Those
actively working and receiving payment must adhere to the
attestations as a requirement of continued employment. If the PCA has
not completed the mandatory orientation, background checks, and CPR
training within ten (10) days prior to the completion time frames,
the Fiscal Intermediary will communicate to the family and the PCA
that the requirement has not been completed by the PCA in the
attested timeframe. The FI will again communicate to the family and
the PCA within five (5) days prior to the completion time frames if
there are still uncompleted requirement(s), that the PCA will not be
paid for services going forward nor will there be retroactive
payment. Such PCAs shall not be included on the PCA Registry until
such time as they have completed all mandatory trainings.
F. EOHHS is responsible for
the review of reported critical incidents with the Advisement Agency
to determine feasibility of continuing participation in the
Independent Provider program.
G. If Medicaid fraud is either
known or suspected, EOHHS shall refer the case to the appropriate
authorities as outlined in the Medicaid Independent Provider Manual,
http://www.eohhs.ri.gov/.
H. A registry of qualified
caregivers shall be posted by EOHHS from information validated by the
Fiscal Intermediary. Listed on the registry are the PCAs who have
completed training requirements and are available to provide
services. Details regarding gender, experience, additional
certifications, languages spoken, town of origin, distance willing to
travel, hours available to work, smoking habits, allergies,
willingness to be called for emergency visits, and a free form
self-description are listed on the registry,
http://www.eohhs.ri.gov/.
1. Individuals working as PCAs
are not required to join the registry when the PCA is only interested
in working for one (1) dedicated consumer.
2. Individuals who are trained
by the consumer for all additional training beyond Mandatory
Orientations (required training for all PCAs participating in the IP
program) are not listed in the registry and cannot work for other
consumers (with the exception of other consumers who also
self-train). No accommodations are made to list provisional providers
on State registries/website.
3. PCAs listed on the registry
have undergone formal training and meet minimum training requirements
in order to participate in the IP program.
4. PCAs may self-initiate
entry into the registry. Information posted on the registry is
validated by the Fiscal Intermediary.
5. Consumers may use the
registry to find and hire PCAs.
6. The frequency of updates to
the registry is dependent on the availability of qualifying PCAs.
7. No consumer information is
listed on the registry.
Attachment I Personal Choice
Assessments and Budget Development
Six (6) Levels of Assistance:
Independent
LTSS
beneficiary is independent in completing the task safely.
Set-Up
LTSS
beneficiary requires brief supervision, cueing, reminder and/or
set- up assistance to perform the task.
Minimum
LTSS
beneficiary is actively involved in the activity, requires some
hands- on assistance for completion, thoroughness or safety. Needs
verbal or physical assistance with twenty-five (25%) of the task.
Moderate
LTSS
beneficiary requires extensive hands-on assistance but is able to
assist in the process. Needs verbal or physical assistance with
fifty percent (50%) of the task.
Extensive
LTSS
beneficiary requires verbal or physical assistance with
seventy-five percent (75%) of the task.
Total
Assistance
LTSS
beneficiary cannot participate or assist in the activity and
requires one hundred percent (100%) assistance with the task.
Not
Applicable
This
task does not apply to this LTSS beneficiary.
Functional
Characteristics for Each ADL/IADL:
ADL/IADL
Functional
Characteristics
Bowel
Behavioral
Issues, Limited
ROM, Spasticity/Muscle Tone
Dressing
Behavioral
Issues, Limited
ROM, Spasticity/Muscle Tone
Eating
Behavioral
Issues, Fine
Motor Deficit, Spasticity/Muscle
Tone
Grooming
Cognitive,
Limited ROM,
Spasticity/Muscle Tone
Mobility
Balance
Problems, Decreased Endurance,
Pain, Spasticity/Muscle Tone
Shower
Balance
Problems, Behavioral Issues, Limited ROM,
Spasticity/Muscle Tone
Skin
Care
Open
Wound
Sponge
Bath
Behavioral
Issues, Limited
ROM, Spasticity/Muscle Tone
Transfers
Balance
Problem, Limited ROM, Spasticity/Muscle Tone
Tub
Bath
Balance
Problem, Behavioral Issues, Limited ROM,
Spasticity/Muscle Tone
Urinary/Menses
Behavioral
Issues, Limited
ROM, Spasticity/Muscle Tone
Communications
No
Functional Characteristics
Housework
LTSS
beneficiary Lives Alone
Meal
Preparation
No
Functional Characteristics
Shopping
No
Functional Characteristics
Activity and Time Allotments,
in minutes:
Activity
Unit
Time
Functional
Time
Sponge
Bath
30
45
Shower
20
40
Tub
Bath
40
45
Dressing
15
20
Eating
20
40
Mobility
10
10
Urinary/Menses
10
15
Transfers
5
10
Grooming
8
8
Skin
Care
10
10
Bowel
30
50
Meal
Preparation
25
25
House
Work
12.5
25
Communications
15
15
Shopping
60
60
Medications
2
5
ADL
Multipliers:
Level
of Assistance
Sponge
Bath
Shower
Tub
Bath
Dressing
Eating
Mobility
Urinary
Menses
Transfers
Grooming
Skin
Care
Bowel
Total
Assist
1
1
1
1
1
1
1
1
1
1
1
Maximum
Assist
.75
.75
.75
.75
.75
1
.75
1
.75
1
.75
Moderate
Assist
.5
.5
.5
.5
.5
.75
.5
.75
.5
.75
.5
Minimum
Assistance
.25
.25
.25
.25
.25
.75
.25
.75
.25
.25
.25
Set-Up
Assistance
.15
.15
.15
.15
.15
.20
.15
.20
.15
.20
.15
Independent
0
0
0
0
0
0
0
0
0
0
0
IADL Multipliers:
Level
of Assistance
Meal
Preparation
Housework
Communications
Shopping
Total
Assist
1
1
1
1
Maximum
Assist
1
1
1
1
Moderate
Assist
.75
.75
.75
1
Minimum
Assistance
.5
.5
.5
1
Set-Up
Assistance
.25
.25
.25
1
Independent
0
0
0
0