Self-Directed Care (formerly The Personal Choice Program)


210-RICR-50-10-2 ACTIVE RULE

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 (2nd) 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 (2nd) 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


Title 210 Executive Office of Health and Human Services
Chapter 50 Medicaid Long-Term Services and Supports
Subchapter 10 Home & Community Based LTSS
Part 2 Self-Directed Care (formerly The Personal Choice Program)
Type of Filing Amendment
Regulation Status Active
Effective 12/15/2020

Regulation Authority :

Chapters 40-6 and 40-8 of the Rhode Island General Laws, as amended; Title XIX of the Social Security Act

Purpose and Reason :

The purpose of this amendment is to allow a prospective Personal Care Attendant (PCA), who is a family member or friend, to provide services and receive 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 that they will complete the necessary background checks and CPR training. These changes will help improve access to care.

 

Additionally, this amendment allows a participant who is identified through the Nursing Home Transition Program /Money Follows the Person Program to be provided with a temporary assessment, in order to facilitate the transition process. The service advisement agency selected by the consumer shall complete an updated assessment within ninety (90) days of the participant returning home.