Introduction

Agency Model Personal Care (PC) services are medically oriented tasks provided as an alternative to nursing facility care and designed to meet the maintenance needs of individuals with chronic health conditions. PC services must be reasonable according to the participant's condition and functional capacity. Home and Community Based Services (HCBS) providers enrolled as PC providers with the Department of Social Services (DSS), Missouri Medicaid Audit and Compliance Unit (MMAC) deliver the services.

Purpose

Agency Model PC services are funded through the Medicaid State Plan and are designed to assist with activities of daily living (ADL) and/or instrumental activities of daily living (IADL). They are provided as an alternative to nursing facility placement to persons for adults and individuals with disabilities. PC is also provided in a Residential Care Facility (RCF) or Assisted Living Facility (ALF) [Needs Link].

Eligibility

All participants must meet the following eligibility criteria:

• At least 18 years of age
• In active Medicaid status (Medicaid Eligibility)
  • Participants who are eligible for Medicaid on a spenddown basis may be authorized to receive PC during periods when they meet their spenddown liability.
  • A participant is responsible for the cost of services received during periods of time when they have not met their spenddown liability.
  • Participants who receive Medicaid due to eligibility for Blind Pension (BP) may be authorized for PC.
  • Participants in a ‘Transfer of Property penalty’ may be authorized for PC.
  • Authorization of PC does not meet the requirements for an individual to be eligible for Home and Community Based (HCB) Medicaid.
  • Have an appropriate Medicaid Eligibility (ME) code [Needs Link].

  • Meet nursing facility level of care.

     

Authorization

PC units shall be authorized as outlined below:

• Authorized in 15-minute units
• Consistent with the PC tasks to be completed on a regular basis

• Reasonable for the amount of PC units authorized

  When developing a Person Centered Care Plan (PCCP) the following shall be taken into consideration:

• PC shall be included in the overall cost of care for the participant as referenced in the HCBS Cost Maximums policy
• PC services shall not exceed 60% of the cost maximum
  • The combination of agency model PC and CDS shall not exceed 60% of the cost maximum.
• The 60% cost maximum can be exceeded by the cost of APC and RN visits, but only up to the full monthly cost of 100%.

NOTE: When the PCCP includes an authorization for RN services, the cost of one RN visit shall be excluded from the calculation of a PCCP’s cost.

• When the combination of PC, other State Plan services, and an HCBS Waiver e.g., Aged and Disabled Waiver (ADW) or Independent Living Waiver (ILW) exceeds 100% of the monthly cost maximum, approval is required from the Bureau of Federal Programs (BFP).
  • The appropriate supervisor for the Division of Senior and Disability Services (DSDS) staff shall review all PCCP requests over the 100% cost maximum to ensure the participant’s unmet needs require the amount of service requested.
  • If documentation supports the request, the case shall be forwarded to BFP for consideration and approval prior to authorization over 100% of the cost cap.
    • Pending the approval from BFP to exceed the cost maximum, PC services in combination with other State Plan or ADW or ILW services can be authorized up to 100% of the cost maximum.
• When a PCCP includes Adult Day Care authorized through the ADW or the Adult Day Care Waiver (ADCW), the total cost of care cannot exceed 100% of the cost maximum.

NOTE: Pursuant to federal guidelines, a participant can only be enrolled in one HCBS waiver at a time, regardless of which department administers the waiver program.

Restrictions

The following outlines guidance to adhere to:

• The individual providing the service is an employee of the HCBS provider and cannot be a member of the immediate family of the participant. An immediate family member is defined as a parent, sibling, child by blood, adoption, or marriage (step-child), spouse, grandparent or grandchild.
• Participants authorized for certain services through the Department of Mental Health (DMH) may not be eligible for services as outlined in this policy. Staff shall refer to the DMH Service Coordination policy [Needs Link] for guidance on coordination of services for participants authorized for DMH services.

Introduction

Advanced Personal Care (APC) (Agency Model) services are maintenance services provided in a participant’s home to assist with activities of daily living (ADL) when this assistance requires devices and procedures related to altered body functions.

Purpose

The authorization of APC services is funded through the Medicaid State Plan. These medically oriented services are designed to meet the physical and maintenance needs of participants with chronic and stable conditions. APC may also be provided in a Residential Care Facility (RCF) or Assisted Living Facility (ALF) through State Plan [Needs Link] (Agency Model).

Eligibility

All APC participants must meet the following eligibility criteria:

• At least 18 years of age
• Meet nursing facility level of care (LOC)
• In active Medicaid status [Needs Link]:
  • Participants eligible for Medicaid on a spenddown basis may be authorized to receive APC when they meet their spenddown liability.
  • A participant is responsible for the cost of services received during periods of time when they have not met their spenddown liability.
  • Participants who receive Medicaid due to eligibility for Blind Pension (BP) may be authorized for APC.
  • Participants in a ‘Transfer of Property penalty’ may be authorized for APC.
  • Authorization of APC does not meet the eligibility requirements for an individual for Home and Community Based (HCB) Medicaid.
• Have an appropriate Medicaid Eligibility (ME) Code [Needs Link]

Authorization of APC

When authorizing APC, the following shall apply:

• APC shall be authorized in increments of 15-minute units
• APC units shall be consistent with the APC tasks to be completed regularly
• The number of APC tasks identified shall be reasonable for authorized APC units
• APC shall be included in the overall monthly cost [Needs Link] of care
• APC is provided by HCBS providers enrolled as a Personal Care-Agency Model provider.
• The APC staff is an employee of the HCBS provider and cannot be a member of the immediate family of the participant. An immediate family member is defined as a parent, sibling, child by blood, adoption, or marriage (stepchild), spouse, grandparent, or grandchild.

Cost Maximus

APC authorized together with other Medicaid State Plan Home and Community Based Services (HCBS) and Aged and Disabled Waiver (ADW), services shall not exceed 100% of the average statewide monthly cost for care in a nursing facility without prior approval of the Bureau of Federal Programs (BFP).

• If the documentation supports the request, the case shall be forwarded to BFP for consideration and approval before authorization over 100% of the cost cap
• Pending BFP approval to exceed the cost cap, APC services, combined with other State Plan or ADW services, can be authorized up to 100% of the cost cap
• When a PCCP includes Adult Day Care authorized through the ADW or the Adult Day Care Waiver (ADCW), the total cost of care cannot exceed 100% of the cost cap

NOTE: When the care plan includes RN services, the cost of one RN visit shall be excluded from calculating a care plan’s cost. When the combination of State Plan and ADW services exceeds the 100% cost maximum, the appropriate supervisor for the Division of Senior and Disability Services (DSDS) staff shall review all person-centered care plan (PCCP) requests over the 100% cost cap to address the participant’s unmet needs.

Restrictions

Participants authorized for certain services through the Department of Mental Health (DMH) may not be eligible for services as outlined in this policy. Staff shall refer to the Service Coordination Policy [Needs Link] for guidance on coordinating services for participants authorized for DMH services.

Allowable Services

Participants who meet eligibility requirements may be authorized for any of the following services:

• Aseptic Dressings: (Suggested time 15 minutes per ordered instance)
  • Application of dressings to superficial skin breaks or abrasions as directed by a licensed nurse
  • Application of medicated (prescription) lotions and ointments to unbroken skin, including stage 1 decubitus
• Assistance with Transfer Device: (Suggested time 15 minutes per instance)
  • Use of an assistive device for transfers
• Bowel/Bladder Program: (Suggested time 15 minutes per ordered instance)
  • Administration of prescribed bowel programs, including suppositories and sphincter stimulation per protocol and prepackaged enemas for participants without contraindicating rectal or intestinal conditions
  • Catheter Hygiene: (Suggested time 15 minutes per instance)
  • Changing of bags, soap and water hygiene around the site of external, indwelling, and suprapubic catheters
  • Removal of external catheters, skin inspection, and catheter reapplication
• Non-Injectable Medications: (Suggested time 15 minutes per ordered instance)
  • Manual assistance with non-injectable medications may include opening a medicine lockbox, steadying the participant’s hand/arm for ear and eye drops, finger sticks for blood sugar monitoring and reading levels and when prompting is required to take medication
• Ostomy Hygiene: (Suggested time 15 minutes per instance)
  • Changing of bags, soap and water hygiene around a well-healed ostomy site (including tracheostomies, gastrostomies, and colostomies)
• Passive Range of Motion: (Suggested time 15 minutes per ordered instance)
  • Administration of movement of a joint through its full range of motion, delivered by the care plan

NOTE: Encouragement (prompting and cueing) and instruction of participants in self-care may be a component of the task; however, encouragement and instruction do not constitute a task in and of themselves.

Introduction

Authorized nurse visits are provided by Home and Community Based Services (HCBS) providers who are enrolled in the HCBS personal care agency model program. The nurse visits are for enhanced supervision of the personal care aide and maintenance, or preventative services provided by a Registered Nurse (RN) or a Licensed Practical Nurse (LPN), or a Graduate Nurse (GN) under the direction of an RN or physician. The visits shall also include an assessment of the participant’s health and the adequacy of the care plan to meet the participant’s needs.

Purpose

Authorized nurse visits are funded through Medicaid State Plan. They are provided to participants with stable, chronic conditions and are NOT typically intended as a treatment for an acute health care condition as normally provided through home health services.

Eligibility

All participants authorized for nurse visits must meet the following eligibility criteria:

• At least 18 years of age
• Meet nursing facility level of care
• In active Medicaid status (Medicaid Eligibility)
  • Participants who are eligible for Medicaid on a spenddown basis may be authorized to receive nurse visits during periods when they meet their spenddown liability.
    
    A participant is responsible for the cost of services received during periods of time when they have not met their spenddown liability.
  • Participants who receive Medicaid due to eligibility for Blind Pension (BP) may be authorized for nurse visits.
  • Participants in a ‘Transfer of Property penalty’ may be authorized for nurse visits.
  • The authorization of nurse visits does not meet the requirement for an individual to be eligible for Home and Community Based (HCB) Medicaid.
• Have an appropriate Medicaid Eligibility (ME) code

NOTE: Participants must be receiving other Personal Care Services (PC) - Agency Model or ConsumerDirected Model (CDS) to be eligible for nurse visits.

Authorization

The following guidelines outline the process for authorizing nurse visits:

• Nurse visits shall be authorized by the visit, not in 15-minute increments. No minimum or maximum time is required to constitute a visit.
• Nurse visits are typically authorized by combining individual nursing tasks into the same nurse visit; however, they can be separated if there is a justified need.
• The nurse is an employee of the HCBS provider and cannot be a member of the immediate family of the participant. An immediate family member is defined as a parent, sibling, child by blood, adoption, or marriage (stepchild), spouse, grandparent or grandchild.
• A maximum of 26 nurse visits will only be provided in a six-month authorization period.
• Authorized nurse visits shall NOT include services considered reimbursable as skilled nursing care under the home health program or when the visit is to determine whether an individual is eligible for HCBS.
  • When a service need is detected that would require skilled nursing care, the provider shall forward information to the participant's physician. The physician may then issue home health orders as appropriate.
• Participants authorized for certain services through the Department of Mental Health (DMH) may not be eligible for services as outlined in this policy. Division of Senior and Disability (DSDS) staff shall refer to the DMH Service Coordination policy for guidance on coordinating services for participants authorized for DMH services.

NOTE: When a provider change occurs, the new provider shall only be authorized for the nurse visit(s) remaining within an existing authorization period.

Cost Maximum

Authorized nurse visitsshall be included in the overall cost of care (HCBS Cost Maximums) with the following exceptions:

• The cost of authorized nurse visits is not included in the 60% monthly maximum cost for basic PC
• The cost of one (1) authorized nurse visit is not included in the 100% monthly cost for basic PC
• Participants who only receive authorized nurse visits for General Health Evaluations (GHE), the cost of two nurse visits shall be excluded from the calculation of a PCCP cost

NOTE: The electronic case record system will automatically exclude the nurse visit(s) from the calculation of the PCCP.

• Nurse visits authorized together with other Medicaid State Plan HCBS, i.e., agency model PC, CDS, Advanced Personal Care (APC) and Aged and Disabled Waiver Services (ADW) shall not exceed 100% of the monthly cost for care in a nursing facility without prior approval from the Bureau of Federal Programs (BFP).
  • When the combination of State Plan and ADW services (excluding Adult Day Care) exceeds the 100% cost maximum:
    • The appropriate supervisor for DSDS staff shall review all PCCP requests to ensure unmet needs require the amount of service requested.
    • If documentation supports the request, it shall be forwarded to BFP for consideration and approval prior to authorizing over 100% of the cost maximum.
    • Pending approval from BFP, authorized nurse visits in combination with other state plan or ADW services can be authorized up to 100% of the cost maximum.

NOTE: When a PCCP includes Adult Day Care authorized through the ADW or the Adult Day Care Waiver (ADCW), the total cost of care cannot exceed 100% of the cost maximum.

General Health Evaluations

All participants receiving agency model PC and APC shall be authorized a minimum of two (2) nurse visits annually to perform General Health Evaluations (GHE) as required by MO State Statute 192.2475.14 RSMo. The semi-annual nurse visits are necessary for the delivery and supervision of the individual providing the services to ensure quality of care, assessment of the participant’s health and adequacy of the participant’s PCCP.

When no other nursing need is identified, GHEs shall be authorized as a task on separate lines in the 4th and 10th months following the (re)assessment as outlined below in the General Health Evaluation Chart.

Excluded from the requirement for semi-annual nurse visits are those participants authorized for:

• Personal Care Services (Agency Model) in a Residential Care Facility (RCF) or Assisted Living Facility (ALF)
• Aged and Disabled Waiver services only
• Personal Care Assistance (Consumer-Directed Model) only
• Independent Living Waiver only
• Adult Day Care Waiver only
• Structured Family Caregiving Waiver

Participants with a documented need for other nurse tasks shall not be authorized for separate semi-annual nurse visits. The 4th and 10th months following a (re)assessment, during which the GHE is to be completed, shall be documented in the electronic case record. DSDS or its designee shall communicate to the provider that the General Health Evaluation (GHE) and Level of Care Recommendation form is to be completed as part of a regularly scheduled nurse visit during those months. GHEs shall not be selected as a task when a participant has a need for nursing tasks. When selecting nurse visits in the electronic case record, only enter the first month of the GHE. The second month will automatically populate.

DSDS or its designee shall be aware of and review documentation/information submitted by the provider nurse and take appropriate action. This includes:

• The General Health Evaluation and Level of Care Recommendation
• Notification that a participant has refused a General Health Evaluation and Level of Care Recommendation visit

NOTE: Critical issues identified during any provider nurse visit shall be communicated immediately to DSDS via telephone, email or fax as required by the Code of State Regulation(s). This notification may require an immediate care plan change.

Regular Nurse Visits

For authorized nurse visits excluding the required semi-annual GHE visits, DSDS or its designee must establish and document that no other person is available who is willing and able to provide the service. Such documentation may include, but is not limited to:

• Participant lives alone
• Incapability of available family members
• Unwillingness/incapability of other available individuals to provide the needed services

• Resident of RCF or ALF requires services beyond what is normally included in the monthly room and board reimbursement to the facility, RCF/ALF PC

  In addition to increased supervision of the HCBS provider employee and assessment of the participant’s health and adequacy of the care plan, authorized nurse visits may include the following:

• Medications
  • Filling insulin syringes weekly for diabetics who can self-inject the medication but cannot fill their own syringes.
    • Documentation must be sufficient to establish the participant has a diabetic condition impairment that prevents the participant from independently filling syringes.
  • Oral medication set-ups in divided daily compartments for participants who self-administer prescribed medications but need assistance and monitoring due to confusion or disorientation.
    • Documentation must be sufficient to establish the need for medication and that the participant is disoriented or confused. Although self-control of prescription and over-the-counter medications may be allowed in an RCF or ALF with written permission from the resident’s physician and allowed by facility policy. This task would not be applicable for RCF and ALF residents who are authorized for Personal Care in an RCF or ALF.
• Monitoring Skin Condition
  • Check for possible skin breakdown due to immobility, incontinence, or other needs as described below.
    • Unable to turn and position self
    • Limited ability to ambulate, with long periods of time sitting or lying in one position, or is documented to be incontinent
    • History of decubitus ulcers, poor circulation evidenced by edema or discolored extremities, and diabetes
      • Documentation must be sufficient to establish the participant is at risk of skin breakdown.
• Nail Care
  • Monthly visits to provide nail care for diabetic participants or participants with other medically contraindicating conditions, including but not limited to participants:
    • Taking anticoagulant medication, such as Coumadin
    • Diagnosed with peripheral vascular disease
    • Diagnosed with a compromised immune system (e.g. HIV and chemotherapy patients)
      • Documentation shall be sufficient to establish the participant has a medical condition such as diabetes AND is unable to perform this task.

Other Nursing Care

Participants may be authorized for nurse visits for specific tasks when the needs of the participant cannot be met and are not reimbursable through the home health program. DSDS or its designee shall approve nurse visits for “other” non-routine nursing tasks after consultation with the participant, provider nurse, DSDS supervisor and, as necessary, the physician.

The “other” nursing tasks may include, but are not limited to:

• Administration of injectable medications (other than insulin)
• Venipunctures
• Catheter changes
• Enemas (only when not utilizing a prepackaged enema)
• Wound dressing changes
• Central line dressing/flush/blood draws

Providers with written documentation should upload it to the participant’s electronic case record and include documentation in case notes.

NOTE: It is not necessary for DSDS or its designee to obtain copies of physician’s orders prior to the authorization of a nurse visit or adding a task to a nurse visit.

Advanced Personal Care

All APC participants shall be authorized for a monthly nurse visit to evaluate the adequacy of service delivery and ensure the participant's needs and conditions are met. During the visit, the nurse assesses the APC aide’s ability to carry out the authorized services.

APC aides shall be trained on the APC tasks delivered. For participants not authorized for weekly nurse visits, an additional nurse visit shall be authorized through the first full month of the authorization for on-the-job training of the APC aide. DSDS staff or its designee shall select the Train APC task for those one-time visits.

The Train APC task shall not be selected for participants authorized for weekly nurse visits. In these circumstances, the Train APC should be authorized as an RN visit for the one-month authorization period. The task should be performed by the nurse during the regular nurse visit as needed.

The Train APC task is to be completed as follows:

• Once during the first full month of an initial authorization of APC, following the addition of an APC task to the care plan
• At the time of an APC provider change
• When requested by the provider (such as when aides change), to provide on-the-job training of the APC aide

When developing the PCCP, two (2) RN visits will be added. One (1) unit will be entered for Train APC, and two (2) units will be entered for Evaluate APC. Eval APC must be authorized for two units in the first month, so the provider can bill for both the training and evaluation of the APC aide later in the same month, since this will be two different visits.

NOTE: To prevent duplicate prior authorizations, the end date and start date of each authorization must not overlap.

Example Of APC Authorization With A Once-A-Month RN Task

1st RN Authorization

2nd RN Authorization

Example Of APC Authorization With Weekly RN Task Included

1st RN Authorization

2nd RN Authorization

Example Of APC Authorization With No Monthly Or Weekly Nurse Visits

1st RN Authorization

2nd RN Authorization

Introduction

Personal Care (PC) services are maintenance services provided to residents of Residential Care Facilities (RCF) or Assisted Living Facilities (ALF) to assist with activities of daily living (ADL). Services are authorized to eligible residents when the resident's needs exceed the facility's minimum obligations as established in the licensure requirements.

RCFs or ALFs are responsible, at a minimum, for the basic human needs of its residents. The facilities are also responsible for assuring the resident's PC needs are met through the resident's resources or other available resources. The facilities are responsible for 24-hour protective oversight of residents and room and board. The reimbursement the facility receives from the resident (Supplemental Security Income (SSI), Social Security Administration (SSA), etc.) and a supplemental cash grant from the Department of Social Services (DSS) is intended to cover safe shelter needs (including housekeeping, basic linens, and the maintenance thereof) and nutritional needs (food and food preparation).

Purpose

RCF/ALF Personal Care services are designed to support residents' additional needs in this setting and are funded through Medicaid State Plan. Basic Personal Care, Advanced Personal Care and Authorized Nurse Visits are all allowable service types offered to residents with an identified need that goes above and beyond the facility's basic requirements.

Eligibility

All PC participants must meet the following eligibility criteria to receive services in an RCF/ALF:

• At least 18 years of age
• In active Medicaid status:
  • Participants eligible for Medicaid on a spenddown basis may be authorized to receive services during periods they meet their spenddown liability.
  • A participant is responsible for the cost of services received during periods of time when they have not met their spenddown liability.
  • Participants who receive Medicaid due to eligibility for Blind Pension (BP) may be authorized for services in the RCF or ALF.
    • Participants in a ‘Transfer of Property penalty’ may be authorized for services in the RCF or ALF.
  • Have an appropriate Medicaid Eligibility (ME) Code.
• Meet nursing facility level of care (LOC)

Referrals

Referrals for PC services shall be made to the Department of Health and Senior Services (DHSS), Division of Senior and Disability Services (DSDS). DSDS shall screen and process the referral as appropriate, utilizing the same timeframes as all other HCBS.

HCBS participants requesting PC services may make a referral by contacting the HCBS Customer Service Center. Providers should initiate referrals by utilizing the Online HCBS Referral Form. In instances when referrals cannot be submitted online, referrals can be submitted by completing the Home and Community Based Services Referral Form. In addition to the referral forms, referrals may include a Physician’s Prescription for Personal Care.

Assessment

When arriving at an RCF/ALF and completing a (re)assessment, DSDS staff or its designee shall:

• Announce themselves to facility staff and indicate the intent of the visit before meeting with the current or potential participant
• Document the room condition where the current or potential participant resides in case notes
• DSDS or its designee must review the participant’s facility chart to verify information that will assist in determining the (LOC) and assistance needed. Items to verify include but are not limited to:
  • Diagnosis and frequency of mental health physician visits
  • Physician-ordered treatments, medications, or special diets the participant receives
• Make other collateral contacts, including, but not limited to, RCF or ALF staff (Administrator/manager, licensed nurse, PC aide who provides daily services), family, friends, legal representatives, or physicians to obtain information to complete the assessment process
• Make decisions regarding the authorization of PC services in consultation and agreement with the participant, the participant’s legal representative (if applicable), and the participant’s physician
• Ensure the services authorized shall reinforce and enhance the participant's current formal and informal support system
  • Reimbursement for PC services cannot duplicate what is covered in other reimbursements to the facility (e.g., routine linen changes and meal preparation).

Authorization

RCF/ALF PC services are also governed by the average statewide monthly cost for care in a nursing facility. PC units shall be authorized as outlined below:

• PC services shall not exceed 60% of the cost maximum
• The 60% cost maximum can be exceeded by the cost of APC and RN visits, but only up to the full monthly cost of 100%
• All combined PC services shall not exceed 100% of the average statewide monthly cost for care in a nursing facility

NOTE: When the care plan includes authorization for RN services, the cost of one RN visit shall be excluded from the calculation of a care plan’s cost.

Tasks

Residents who meet the necessary Medicaid eligibility requirements may be authorized for any of the following combinations of services provided.

Basic Personal Care

Basic Personal Care (PC) services in RCF/ALF shall be authorized in 15-minute units and are generally medically oriented tasks designed to meet the physical and maintenance needs of participants with chronic, stable conditions. PC may include the following tasks:

• Bathing
  • Direct assistance with bathing and shampooing hair that requires active participation by the aide. (e.g. hands-on washing assistance, assistance in or out of the bath, gathering supplies/clean clothing, etc.) (Suggested time 15-45 minutes per bath)
• Dietary
  • Direct assistance with meal preparation, feeding and clean up. Dietary shall be authorized when the participant has a physician-ordered specialized diet. Dietary may also be authorized if the participant needs assistance with feeding, cutting up food, carrying a tray to the table, opening containers, etc. Authorization of service units must be based on the participant’s specific needs. (Suggested time 15- minutes per meal)
  • DSDS or its designee shall review any physician-ordered diet before authorizing units for dietary needs. No units shall be authorized for meal preparation and clean-up unless facility staff exceeds licensure requirements.
• Dressing/Grooming
  • Direct assistance with dressing and undressing, combing hair, nail care, oral hygiene, shaving, and assisting with prosthetics. (Suggested time 15 minutes per dressing instance)
• Medically Related Household Tasks
  • Assistance with required cleaning that goes above and beyond the minimum housekeeping requirements of the facility. Time may be authorized if the participant has a medically related need that requires the facility staff to clean a resident’s living area more often than usual (e.g. profuse bodily secretions, excess bodily fluids from incontinence, destructive tendencies, hoarding, etc.). DSDS or its designee can authorize services to clean the resident’s living area and launder the resident’s clothes and linens. (Suggested time 15-minutes per instance)
• Mobility and Transfer
  • Direct assistance with mobility, transfer, and ambulation when the participant can at least partially bear their weight. (Suggested time 5-10 minutes per instance)
• Self-Administration of Medications
  • Direct assistance with medications and applying nonprescription topical ointments or lotions (e.g. the time spent handling the medication container, including inhalers, medicines for nebulizers, ointments/lotions, steadying the participant’s hand/arm to get oral medication and inhalants to mouth, and water to the participant. (Suggested time 1 unit/day for self-administration of medications taken up to 3 times daily; 2 units/day for medications taken 4 or more times daily)
    • Medication administration is not a covered task within the PC program. The self-administration of medication task does not include the time required by facility staff to administer the medication. Administration of medication is defined in 19 CSR 30-86.042(51) as delivered to a resident their prescription medication either in the original pharmacy container or for internal medication, removing an individual dose from the pharmacy container and placing it in a small container or liquid medium for the resident to remove from the container and self-administer.
• Toileting
  • Direct assistance with toileting tasks. This may include assistance using or transferring to/from the toilet, commode, bedpan, urinal, cleansing after use and assistance with incontinence episode(s) (The suggested time is 5 minutes multiplied by times per day based upon the suggested frequency needed).
    • Encouragement (prompting and cueing) and instruction of participants in self-care may be a component of the services; however, encouragement and instruction do not constitute a task in and of themselves.

Advanced Personal Care

Advanced Personal Care (APC) services shall be authorized in 15-minute units and are medically oriented tasks designed to meet the physical and maintenance needs of participants with a chronic, stable condition when such assistance requires devices and procedures related to altered body functions. APC may include the following tasks:

• Aseptic Dressings
  • Application of dressings to superficial skin breaks or abrasions as directed by a licensed nurse. (Suggested time 15 minutes per ordered instance)
  • Application of medicated (prescription) lotions and ointments to unbroken skin, including stage 1 decubitus. (Suggested time 15 minutes per ordered instance)
• Bowel Program
  • Administration of prescribed bowel programs, including suppositories and sphincter stimulation per protocol and prepackaged enemas for participants without contraindicating rectal or intestinal conditions. (Suggested time 15 minutes per ordered instance)
• Catheter Hygiene
  • Changing of bags, soap and water hygiene around the site of external, indwelling, and suprapubic catheters. (Suggested time 15- minutes per instance)
  • Removal of external catheters, skin inspection, and catheter reapplication. (Suggested time 15- minutes per instance)
• Non-Injectable Medications
  • Manual assistance with non-injectable medications, as set up by a licensed nurse, may include opening a medicine lockbox, steadying the participant’s hand/arm for ear and eye drops, finger sticks for blood sugar monitoring and reading levels and when prompting is required to take medication. (Suggested time 15 minutes per ordered instance)
• Ostomy Hygiene
  • Changing of bags, soap and water hygiene around a well healed ostomy site (including tracheostomies, gastrostomies, and colostomies). (Suggested time 15- minutes per instance)
• Passive Range of Motion
  • Administration of movement of a joint through its full range of motion, delivered in accordance with the care plan. (Suggested time 15 minutes per ordered instance)

Authorized Nurse Visits

Authorized Nurse Visits (RN) are authorized by the visit. No minimum or maximum time is required to constitute a visit. RN services are maintenance or preventative services provided by a Registered Nurse (RN) or a Licensed Practical Nurse (LPN) under an RN's or physician's direction.

Authorized Nurse Visit tasks may include:

• Evaluate APC Care Plan
  • All APC participants shall be authorized for an RN visit monthly to evaluate the adequacy of the authorized services to meet the participant’s needs and assess the APC aide’s ability to carry out the authorized services.
• Other RN Care
  • Monitor skin condition(s)
  • Nail care: Monthly visits to provide nail care for diabetic participants or participants with other medically contraindicating conditions, including but not limited to participants:
    • Taking anticoagulant medication
    • Diagnosed with peripheral vascular disease
    • Diagnosed with a compromised immune system
  • Administration of injectable medications (other than insulin)
  • Venipunctures
  • Catheter changes
  • Enemas (only when not utilizing a prepackaged enema)
  • Central line dressing/flush/blood draws

Introduction

Personal Care Assistance Consumer Directed Services (CDS) is a Home and Community Based Services (HCBS) program offered through the Division of Senior and Disability Services (DSDS). CDS is available to participants who can direct their own care and can live independently. CDS participants select an HCBS provider that is enrolled as a CDS provider with the Department of Social Services (DSS), Missouri Medicaid Audit and Compliance (MMAC) Unit. Payment is made to the HCBS provider on behalf of the participant. The HCBS provider processes payroll, on behalf of the participant, to the individual providing the services.

Authorization of Personal Care Assistance is funded through both the Consumer-Directed Model Medicaid State Plan and the Independent Living Waiver (ILW). This policy addresses State Plan services only. Refer to the ILW Policy [Needs Link] for additional information regarding services through the ILW.

Purpose

CDS provides assistance with activities of daily living (ADL) and/or instrumental activities of daily living (IADL) provided as an alternative to nursing facility placement to persons with a physical disability.

Eligibility

All CDS participants must meet the following eligibility criteria:

• Be at least eighteen (18) years of age
• Be physically disabled, as defined by 19 CSR 15-8.100
  • Loss of, or loss of use of, all or part of the body's neurological, muscular, or skeletal functions to the extent the person requires the assistance of another person to accomplish routine tasks.
• Be able to self-direct their CDS
• In active Medicaid [Needs Link] status
  • Participants eligible for Medicaid on a spenddown basis may be authorized to receive CDS during periods when they meet their spenddown liability.
    • During periods when the participant has not met their monthly spenddown liability amount, the participant and provider may make a private arrangement for the continued delivery of services. In these instances, the participant is responsible for the cost of services received.
  • Participants who receive Medicaid due to eligibility for Blind Pension (BP) may be authorized for CDS.
  • Participants in a ‘Transfer of Property penalty’ may be authorized for CDS.
  • Authorization of CDS does not meet the requirements for an individual to be eligible for Home and Community Based (HCB) Medicaid.
• Have an appropriate Medicaid Eligibility (ME) Code [NEEDS LINK]
• Meet nursing facility level of care (LOC)
• Have not been previously involved in Medicaid fraud