NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and
Family Services, Department for Medicaid Services has responsibility to
administer the Medicaid Program.
KRS
205.520(3) authorizes the
cabinet to comply with any requirement that may be imposed, or opportunity
presented, by federal law to qualify for federal Medicaid funds. This
administrative regulation establishes the coverage provisions and requirements
for home and community based waiver services version 2.
Section 1. Definitions.
(1) "1915(c) home and community based
services waiver program" means a Kentucky Medicaid program established pursuant
to and in accordance with 42
U.S.C.
1396n(c).
(2) "Abuse" regarding:
(a) An adult is defined by
KRS
209.020(8); or
(b) A child means abuse pursuant to KRS
Chapter 600 or 620.
(3)
"ADHC" means adult day health care.
(4) "ADHC center" means an adult day health
care center licensed in accordance with
902 KAR 20:066.
(5) "ADHC services" means health-related
services provided on a regularly-scheduled basis that ensure optimal
functioning of a participant who:
(a) Does not
require twenty-four (24) hour care in an institutional setting; and
(b) May need twenty-four (24) hour respite
services when experiencing a short-term crisis due to the temporary or
permanent loss of the primary caregiver.
(6) "Advanced practice registered nurse" or
"APRN" is defined by KRS
314.011(7).
(7) "Area agency on aging and independent
living" means:
(a) An area agency on living as
defined by 42 U.S.C.
3002(6); and
(b) A local agency designated by the
Department for Aging and Independent Living to administer funds received under
Title III for a given planning and service area.
(8) "Assessment" means an evaluation
completed using the Kentucky Home Assessment Tool (K-HAT).
(9) "Blended services" means a
non-duplicative combination of HCB waiver services that are not
participant-directed services as well as participant-directed
services.
(10) "Center for
independent living" is defined by
42 U.S.C.
796a(1).
(11) "Certified nutritionist" is defined by
KRS
310.005(12).
(12) "Certified social worker" means an
individual who meets the requirements established in
KRS
335.080.
(13) "Chemical restraint" means a drug or
medication:
(a) Used to restrict an
individual's:
1. Behavior; or
2. Freedom of movement; and
(b)
1. That is not a standard treatment for the
individual's condition; or
2.
Dosage that is not an appropriate dosage for the individual's
condition.
(14) "Communicable disease" means a disease
that is transmitted:
(a) Through direct
contact with an infected individual;
(b) Indirectly through an organism that
carries disease-causing microorganisms from one (1) host to another or a
bacteriophage, a plasmid, or another agent that transfers genetic material from
one (1) location to another; or
(c)
Indirectly by a bacteriophage, a plasmid, or another agent that transfers
genetic material from one (1) location to another.
(15) "DAIL" means the Department for Aging
and Independent Living.
(16) "DCBS"
means the Department for Community Based Services.
(17) "Department" means the Department for
Medicaid Services or its designee.
(18) "Electronic signature" is defined by
KRS
369.102(8).
(19) "Experimental goods or services" means
goods or services that are serving the ends of or used as a means of
experimentation.
(20)
"Exploitation" regarding:
(a) An adult is
defined by KRS
209.020(9); or
(b) A child means exploitation pursuant to
KRS Chapter 600 or 620.
(21) "Home and community based waiver
services" or "HCB waiver services" means home and community based waiver
services:
(a) Covered by the department
pursuant to this administrative regulation; and
(b) For individuals who meet the requirements
of Section 4 of this administrative regulation.
(22) "Home and community support services"
means nonresidential and nonmedical home and community based services and
supports that:
(a) Meet the participant's
needs; and
(b) Constitute a
cost-effective use of funds.
(23) "Home delivered meal provider" means a
food service establishment as defined by
KRS
217.015(21).
(24) "Home health agency" means an agency
that is:
(b) Medicare and Medicaid
certified.
(25) "Illicit
drug" means:
(a) A drug, prescription or not
prescription, used illegally or in excess of therapeutic levels; or
(b) A prohibited drug.
(26) "Immediate family member" is defined by
KRS
205.8451(3).
(27) "Informed choice" means a choice among
options based on accurate and thorough knowledge and understanding to the
participant regarding:
(a) The services and
supports to be received; and
(b)
From whom services and supports will be received.
(28) "Legally responsible individual" means
an individual who:
(a) Has a duty under state
law to care for another person; and
(b)
1. Is a
parent (biological, adoptive, or foster) of a minor child and provides care to
the child;
2. Is the guardian of a
minor child and provides care to the child; or
3. Is a spouse of a participant.
(29) "Licensed clinical
social worker" means an individual who meets the requirements established by
KRS
335.100.
(30) "Licensed dietitian" is defined by
KRS
310.005(11).
(31) "Licensed medical professional" means:
(a) A physician;
(b) An advanced practice registered
nurse;
(c) A physician
assistant;
(d) A registered
nurse;
(e) A licensed practical
nurse; or
(f) A
pharmacist.
(32)
"Licensed practical nurse" or "LPN" means a person who:
(a) Meets the definition established by
KRS
314.011(9); and
(b) Works under the supervision of a
registered nurse.
(33)
"Licensed social worker" means an individual who meets the requirements
established by KRS
335.090.
(35) "Natural supports" means a non-paid
person, persons, primary caregiver, or community resource who can provide or
has historically provided assistance to the participant or due to the familial
relationship would be expected to provide assistance.
(36) "Neglect" regarding:
(a) An adult is defined by
KRS
209.020(016); or
(b) A child means neglect pursuant to KRS
Chapter 600 or 620.
(37)
"NF" means nursing facility.
(38)
"NF level of care" means a high intensity or low intensity patient status
determination made by the department in accordance with
907 KAR 1:022.
(39) "Normal baby-sitting" means general care
provided to a child that includes custody, control, and supervision.
(40) "Normal care sitting" means general
care:
(a) Provided to an adult who is at least
eighteen (18) years of age; and
(b)
That includes custody, control, and supervision.
(41) "Participant" means a recipient who
meets the:
(b) Eligibility criteria for HCB waiver
services established in Section 4 of this administrative regulation.
(42) "Participant corrective
action plan" means a written plan that is developed by the case manager or
service advisor in conjunction with the participant or representative to
identify, eliminate, and prevent future violations from occurring by:
(a) Providing the participant or
representative with the specific administrative regulation that has been
violated;
(b) Identifying factual
information regarding the violation; and
(c) Reaching an agreement between the case
manager and the participant or representative to the resolution and being in
compliance within the timeframe established in the participant corrective
action plan being issued.
(43) "PDS" means participant-directed
services.
(44) "Person-centered
service plan" means a written individualized plan of services for a participant
that meets the requirements established in Section 7 of this administrative
regulation.
(45) "Person-centered
team" means a participant, the participant's guardian or representative, and
other individuals who are natural or paid supports and who:
(a) Recognize that evidenced based decisions
are determined within the basic framework of what is important for the
participant and within the context of what is important to the participant
based on informed choice;
(b) Work
together to identify what roles they will assume to assist the participant in
becoming as independent as possible in meeting the participant's needs;
and
(c) Include providers who
receive payment for services and who shall:
1.
Be active contributing members of the person-centered team meetings;
2. Base their input upon evidence-based
information; and
3. Not request
reimbursement for person-centered team meetings.
(46) "Physical restraint" means
any manual method or physical or mechanical device, material, or equipment
that:
(a) Immobilizes or reduces the ability
of a person to move his or her arms, legs, body, or head freely; and
(b) Does not include:
1. Orthopedically prescribed devices or other
devices, surgical dressings or bandages, or protective helmets; or
2. Other methods that involve the physical
holding of a person for the purpose of:
a.
Conducting routine physical examinations or tests;
b. Protecting the person from falling out of
bed; or
c. Permitting the person to
participate in activities without the risk of physical harm.
(47)
"Physician assistant" or "PA" is defined by
KRS
311.840(3).
(48) "Plan of treatment" means a care plan
developed and used by an ADHC center based on the participant's individualized
ADHC service needs, goals, interventions, and outcomes.
(49) "Prohibited drug" means a drug or
substance that is illegal under KRS Chapter 218A.
(50) "Public health department" means an
agency recognized by the Department for Public Health pursuant to 902 KAR
Chapter 8.
(51) "Recipient" is
defined by KRS
205.8451(9).
(52) "Registered nurse" or "RN" means a
person who:
(a) Meets the definition
established by KRS
314.011(5); and
(b) Has one (1) year or more experience as a
professional nurse.
(53)
"Representative" is defined by
KRS
205.5605(6).
(54) "Service advisor" is defined by
KRS
205.5605(7).
(55) "Sex crime" is defined by
KRS
17.165(1).
(56) "Violent crime" is defined by
KRS
17.165(3).
(57) "Violent offender" is defined by
KRS
17.165(2).
Section 5. Covered Services and Related
Requirements.
(1)
(a) HCB waiver services shall include:
1. Conflict free case management;
2. Attendant care;
3. Specialized respite care
services;
4. Environmental or minor
home adaptations;
5. ADHC
services;
6. Goods and services;
or
7. Home delivered
meals.
(b)
1. Participant-directed services shall
include:
a. Environmental or minor home
adaptations;
b. Goods and
services;
c. Home and community
supports;
d. Non-specialized
respite care services; or
e. PDS
coordination services.
2. Participant-directed services provided to
a participant shall not replace the participant's natural support
system.
(2)
(a) An HCB waiver service and a PDS, except
as established in subparagraph 3 of this paragraph, shall:
1. Be prior authorized by the department
based upon a request that provides all of the information needed to ensure that
the service or modification of the service meets the needs of the
participant;
2. Be provided
pursuant to the participant's person-centered service plan;
3. Except for PDS, not be provided by an
immediate family member, guardian, or legally responsible individual of the
participant;
4. Be accessed within
sixty (60) days of the date of prior authorization;
5. Be a one (1) on one (1) encounter except
for:
a. An ADHC service in which case the ADHC
center providing the service shall comply with the ADHC personnel requirements
established in
902 KAR 20:066; or
b. A service for which a one (1) on one (1)
encounter is not appropriate due to the participant's circumstances or
condition in which case the circumstances or condition shall be documented in
the:
(i) Assessment; and
(ii) Person-centered service plan;
6. Not occur at the
same time as another service, regardless of payer source, except for a:
a. Doctor visit; or
b. Physical therapy, occupational therapy, or
speech-language pathology service appointment; and
7. Be provided by an individual who:
a. Does not have a communicable disease
pursuant to Section 2(3)(f) of this administrative regulation; and
b. Provides services at a level that
appropriately and safely meets the needs of the participant.
(b) A 1915(c) home and
community based waiver service that is not part of a hospice service package
may be covered in conjunction with hospice services.
(3) To request prior authorization:
(a) For a non-PDS HCB waiver service, a case
manager shall submit a completed person-centered service plan to the
department; or
(b) For a PDS, a
service advisor shall submit a completed person-centered service plan to the
department.
(4) Except
for case management and PDS coordination, services shall not begin and payment
shall not be made for services until:
(a) A
level of care determination has been approved by the department;
(b) A person-centered service plan has been:
1. Developed by the person-centered team;
and
2. Approved by the department;
and
(c)
1. DCBS has determined that the individual
meets financial eligibility requirements and valid documentation of eligibility
is on file for a new applicant for Medicaid; or
2. The first day of the month following the
level of care determination if the applicant is a recipient currently enrolled
with a managed care organization. The managed care organization shall be
responsible for ensuring the applicant's health, safety, and welfare during the
period between the level of care determination and the first day of the month
following the level of care determination.
(5)
(a) Case
management requirements shall be as established in Section 8 of this
administrative regulation.
(b)
Except for the requirement established in Section 8(7)(b), the requirements
established in Sections 6 and 8 of this administrative regulation shall apply
to service advisors.
(6)
(a) An attendant care service shall provide
care that consists of:
1. General household
activities including:
a. Cleaning;
b. Cooking; or
c. Chores;
2. Personal care services including
assistance with:
a. Bathing;
b. Grooming;
c. Dressing;
d. Eating;
e. Toileting;
f. Transferring;
g. Assistance with self-administration of
medication; or
h. Ambulation;
or
3. Transporting a
participant to a needed place as specified in the participant's person-centered
service plan including:
a. A
grocery;
b. A pharmacy;
or
c. An appointment.
(b)
1. An individual transporting a participant
shall have a valid driver's license.
2. A minimum of current liability insurance
shall be required for a vehicle used to transport a participant.
(c)
1. An attendant care provider shall maintain
a sign in and out log documenting the provision of services to
participants.
2. Documentation
shall include:
a. The date the service was
provided;
b. The duration of the
service;
c. The arrival and
departure time of the provider;
d.
A description of the service provided; and
e. The name, title, and signature of the
staff who provided the service.
(7)
(a) A
specialized respite care service shall:
1. Be
short-term care based on the absence or need for relief of the non-paid primary
caregiver;
2. Be provided by staff
who provides services at a level that appropriately and safely meets the needs
of the participant;
3. Be provided
to a participant who has care needs beyond normal baby-sitting or normal care
sitting;
4. If the participant
receiving the service is assessed pursuant to
907 KAR 7:015 as qualifying the
provider for Level II reimbursement, have twenty-four (24) hour access to an RN
for emergency situations and consultations; and
(b)
1. A provider of specialized respite care
shall maintain a sign in and out log documenting the provision of services to
participants.
2. Documentation
shall include:
a. The date the service was
provided;
b. The duration of the
service;
c. The arrival and
departure time of the provider;
d.
A description of the service provided; and
e. The name, title, and signature of the
staff who provided the service.
(8)
(a) An
environmental or minor home adaptation service shall:
1. Be a physical adaptation to a home owned
by the participant or family member of the participant that is necessary to
ensure the health, welfare, and safety of the participant;
2. Meet all applicable safety and local
building codes;
3. Relate strictly
to the participant's disability and needs;
4. Exclude an adaptation or improvement to a
home that has no direct medical or remedial benefit to the
participant;
5. Be provided by a
licensed and insured provider qualified to provide the modification;
6. Not add to the total square footage of a
home except if necessary to complete an adaptation;
7. Be submitted on the person-centered
service plan for prior authorization; and
8. Not be covered unless prior
authorized.
(b) A
personal emergency response system shall be considered a covered environmental
or minor home adaptation if it meets the requirements established in this
subsection.
(9)
(a) An ADHC service shall:
1. Be provided to a participant who is at
least twenty-one (21) years of age;
2. Include the following basic services and
necessities provided to participants during the posted hours of operation:
a. Skilled nursing services provided by an RN
or LPN, including ostomy care, urinary catheter care, decubitus care, tube
feeding, venipuncture, insulin injections, tracheotomy care, or medical
monitoring;
b. Meal service
corresponding with hours of operation with a minimum of one (1) meal per day
and therapeutic diets as required;
c. Snacks;
d. The presence of an RN or LPN;
e. Age and diagnosis appropriate daily
activities; and
f. Routine services
that meet the daily personal and health care needs of a participant, including:
(i) Monitoring of vital signs;
(ii) Assistance with activities of daily
living; and
(iii) Monitoring and
supervision of self-administered medications, therapeutic programs, and
incidental supplies and equipment needed for use by a participant;
3. Include developing,
implementing, and maintaining nursing policies for nursing or medical
procedures performed in the ADHC center;
4. Include specialized respite care services
pursuant to subsection (7) of this section;
5. Be provided to a participant by the health
team in an ADHC center, which may include:
a.
A physician;
b. A physician
assistant;
c. An APRN;
d. An RN;
e. An LPN;
f. An activities director;
g. A licensed social worker;
h. A certified social worker;
i. A licensed clinical social
worker;
j. A certified
nutritionist; or
k. A health aide;
and
6. Be provided
pursuant to a plan of treatment that is included in the participant's
person-centered service plan.
(b) A plan of treatment shall:
1. Be developed and signed by each member of
the plan of treatment team, which shall include the participant, participant's
guardian, or participant's legal representative;
2. Include:
a. Pertinent diagnoses;
b. Mental status;
c. Services required;
d. Medication or food allergies and special
diet;
e. Contradictions for
specific types of activities and preventive health care measures;
f. Frequency of visits to the ADHC
center;
g. Prognosis;
h. Rehabilitation potential;
i. Functional limitation;
j. Activities permitted;
k. Nutritional requirements;
l. Medication;
m. Treatment;
n. Safety measures to protect against
injury;
o. Instructions for timely
discharge; and
p. Other pertinent
information; and
3. Be
developed annually from information on the assessment and revised as
needed.
(c)
1. Modification of an ADHC unit of service
shall require:
a. Modification of the
participant's person-centered service plan; and
b. Prior authorization.
2. Upon approval or denial of a prior
authorization request, the department shall provide written notification to the
case manager and to the participant.
3. A case manager shall:
a. Inform the ADHC center of approval or
denial; and
b. Document the
approval or denial in the case record.
(d)
1. An
ADHC center shall maintain a sign in and out log documenting the provision of
services to participants.
2.
Documentation shall include:
a. The date the
service was provided;
b. The
duration of the service;
c. The
arrival and departure time of the participant;
d. A description of the service provided;
and
e. The title, name, and
signature of the staff who provided the service.
(10) Goods and services
shall:
(a) Be individualized;
(b) Meet identified needs required by the
participant's person-centered service plan that are necessary to ensure the
health, welfare, and safety of the participant;
(c) Be items that are utilized to reduce the
need for personal care or to enhance independence within the participant's home
or community;
(d) Not include
experimental goods or services;
(e)
Not include chemical or physical restraints; and
(f) Not be covered unless prior authorized by
the department.
(11) A
home delivered meal shall:
(a) Meet at least
one-third (1/3) of the recommended daily allowance per meal and meet the
requirements of the current version of the Dietary Guidelines for Americans
published by United States Department of Agriculture and the United States
Department of Health and Human Services;
(b) Be provided to a participant who is
unable to prepare his or her own meals and for whom there are no other persons
available to do so including natural supports;
(c) Be furnished in accordance with menus
that are approved in writing by a licensed dietitian;
(d) Take into consideration the participant's
medical restrictions; religious, cultural, and ethnic background; and dietary
preferences;
(e) Be individually
packaged heated meals;
(f) Be
provided for inclement weather, holidays, or emergencies if prior approval is
provided by the department and if the meals:
1. Are individually packaged if not
heated;
2. Are shelf stable;
or
3. Have components separately
packaged if the components are clearly marked as components of a single meal;
and
(g) Not:
1. Supplement or replace meal preparation
activities that occur during the provision of attendant care services or any
other similar service;
2.
Supplement or replace the purchase of food or groceries;
3. Include bulk ingredients, liquids, and
other food used to prepare meals independently or with assistance;
4. Be provided while the participant is
hospitalized, residing in an institutional setting, or while in attendance at
an ADHC center; or
5. Duplicate a
service provided through other programs operated by any governmental
agency.
(12)
(a) Home and community support services shall
consist of:
1. General household activities
including;
a. Cleaning;
b. Cooking; or
c. Chores;
2. Personal care services including
assistance with:
a. Bathing;
b. Grooming;
c. Dressing;
d. Eating;
e. Toileting;
f. Transferring;
g. Assistance with self-administration of
medication; or
h. Ambulation;
or
3. Transporting a
participant to a needed place as specified in the participant's person-centered
service plan including:
a. A
grocery;
b. A pharmacy;
or
c. An appointment.
(b)
1. An individual transporting a participant
shall have a valid driver's license.
2. A minimum of current liability insurance
shall be required for a vehicle used to transport a participant.
(13) Non-specialized
respite care shall be provided:
(a) To a
participant who has care needs beyond normal baby-sitting or normal care
sitting; and
(b) In relief of a
non-paid primary caregiver.
(14)
(a) PDS
coordination services shall include service advisory and management of
funds.
(b) The financial management
service provider shall:
1. Perform, on behalf
of the participant, the employer responsibilities of payroll processing, which
shall include:
a. Issuing paychecks;
b. Withholding federal, state, and local tax
and making tax payments to the appropriate tax authorities; and
c. Issuing W-2 forms;
2. Be responsible for performing all fiscal
accounting procedures at least every thirty (30) days including issuing
expenditure reports to:
a. The participant,
the participant's guardian, or the participant's legal
representative;
b. The
participant's case manager; and
c.
Upon request, the department;
3. Maintain a separate account for each
participant while continually tracking and reporting funds, disbursements, and
the balance of the participant's prior authorizations; and
4. Process and pay invoices for:
a. PDS goods and services approved in the
person-centered service plan; and
b. Environmental or minor home adaptations in
the person-centered service plan.
Section 6. Miscellaneous
Participant-Directed Services Requirements.
(1) A PDS provider shall:
(a) Be selected by the participant;
(b) Be at least eighteen (18) years of
age;
(c) Be a citizen of the United
States with a valid Social Security number or possess a valid work permit if
not a U.S. citizen;
(d) Be able to
communicate effectively with the participant, representative, participant's
guardian, or family of the participant;
(e) Be able to understand and carry out
instructions;
(f) Be able to keep
records as required by the participant;
(g) Comply with the requirements for
background and related checks established in Section 2(3)(j) of this
administrative regulation;
(h) Not
be a PDS provider excluded from providing services in accordance with Section
2(3)(k) of this administrative regulation;
(i)
1. Prior
to the beginning of employment, complete training on the:
a. Reporting of abuse, neglect, or
exploitation in accordance with
KRS
209.030 or
620.030; and
b. Needs of the participant; and
2. Receive DAIL attendant care
training initially and then annually thereafter;
(j)
1.
Obtain first aid certification within six (6) months of providing PDS services;
and
2. Maintain first aid
certification for the duration of being a PDS provider;
(k)
1.
Except as established in subparagraph 2 of this paragraph:
a. Obtain cardiopulmonary resuscitation (CPR)
certification by a nationally accredited entity within six (6) months of
employment; and
b. Maintain CPR
certification for the duration of being a PDS provider; or
2. If the participant to whom a PDS provider
provides services has a signed Do Not Resuscitate order, not be required to
meet the requirements established in subparagraph 1 of this
paragraph;
(l) Comply
with the TB risk assessment and test requirements established in Section
2(3)(h)5. of this administrative regulation;
(m) Maintain and submit timesheets:
1. Signed by the:
a. Participant or representative;
and
b. Provider; and
2. Documenting:
a. Hours worked;
b. The provision of a service including:
(i) A full description of the service
provided; and
(ii) Any concerns or
issues, if existing, regarding the general well-being of the participant;
and
c. The participant's
choice of daily activities and services; and
(n) Submit a completed Kentucky Consumer
Directed Options/Participant Directed Services Employee/Provider Contract to
the service advisor.
(2)
(a) A participant may designate a
representative to act on the participant's behalf.
(b) A representative shall:
1. Submit to all of the background and
related checks established in Section 2(3)(j) of this administrative
regulation;
2. Be at least eighteen
(18) years of age;
3. Be chosen by
the participant, except as established in paragraph (c) of this subsection, to
manage and direct all related aspects of the participant's PDS; and
4. Not be a PDS representative if found in
violation of the provisions established in subsection (1)(h) of this
section.
(c) A
representative shall be chosen for a participant if a condition established in
this paragraph exists. If the participant:
1.
Is under eighteen (18) years of age, a family member of the participant shall
appoint a representative for the participant;
2. Has a guardian or legal representative,
the participant's guardian or legal representative shall appoint a
representative for the participant; or
3. Has failed to adhere to the terms of a
participant corrective action plan and chooses to continue receiving PDS, the
participant's person-centered team shall present a list of multiple potential
representatives to the participant from which the participant shall choose a
representative.
(d) A
participant's choice of representative shall be made via a MAP-2000,
Initiation/Termination of Consumer Directed Option (CDO)/Participant Directed
Services (PDS), which the participant shall submit to the participant's service
advisor.
(3) A
participant may voluntarily terminate PDS by completing a MAP-2000,
Initiation/Termination of Consumer Directed Option (CDO)/Participant Directed
Services (PDS) and submitting it to the participant's service
advisor.
(4) The department shall
immediately terminate a participant from receiving PDS if:
(a) Imminent danger to the participant's
health, safety, or welfare exists; or
(b) The participant's person-centered service
plan indicates he or she requires more hours of service than the program can
provide, which may jeopardize the participant's safety and welfare due to being
left alone without a caregiver present.
(5) A service advisor:
(a) Providing PDS coordination shall:
1. Meet the case manager requirements
established in Section 8(1) and (2) of this administrative regulation;
and
2. Within seven (7) days of
receiving a referral regarding a participant from an independent assessor,
schedule a face-to-face visit with the participant, the participant's guardian,
or the participant's legal representative;
(b) Shall work with the participant or
participant's legal representative to develop a participant corrective action
plan:
1. If the participant, participant's
legal representative, or PDS employee has exhibited abusive, intimidating, or
threatening behavior; or
2.
Pursuant to Section 8(7)(d) of this administrative regulation;
(c) For a participant with a
participant corrective action plan:
1. Shall
monitor the progress of the participant corrective action plan; and
2.
a. Shall
determine that the participant corrective action plan has been satisfied and
continue with PDS;
b. May assist or
direct the participant in appointing a representative pursuant to subsection
(2)(c) of this section; or
c. Shall
proceed with involuntary termination of PDS if the participant or legal
representative is unable or unwilling to comply with the participant corrective
action plan;
(d) If proceeding with involuntary
termination, shall:
1. Notify the independent
assessor in writing of termination of PDS within thirty (30) days;
2. Provide the participant or participant's
legal representative with written information regarding the traditional waiver
program and traditional waiver providers;
3. Provide the participant or participant's
legal representative with information regarding the right to appeal the PDS
denial in accordance with
907 KAR 1:563;
4. Complete and submit to the department a
MAP-2000, Initiation/Termination of Consumer Directed Option (CDO)/Participant
Directed Services (PDS) terminating the participant from PDS; and
5. Document the:
a. Reason for the termination;
b. Actions taken to assist the participant
with the participant corrective action plan; and
c. Outcomes; and
(e) Shall conduct at least one (1)
in person visit with:
1. The participant each
month at the:
a. Participant's residence;
or
b. ADHC center if the
participant receives services at an ADHC center; and
2. The participant's representative each
three (3) months if designated by the participant.
(6) Except as provided
in subsection (4) or (5) of this section regarding a participant's termination
from PDS, the participant's service advisor shall:
(a) Notify the independent assessor and
service provider of potential termination;
(b) Assist the participant in developing a
participant corrective action plan;
(c) Allow at least thirty (30) but no more
than ninety (90) days for the participant to resolve the issue, develop and
implement a prevention plan, or designate a PDS representative;
(d) Complete and submit to the department a
MAP-2000, Initiation/Termination of Consumer Directed Option (CDO)/Participant
Directed Services (PDS) terminating the participant from receiving PDS if the
participant fails to meet the requirements established in paragraph (c) of this
subsection; and
(e) Assist the
participant in transitioning back to traditional HCB services by providing a
current list of traditional HCB service providers.
(7) A personal services agency shall:
(b) Comply with the requirements of this
section.
(8) An
immediate family member, guardian, or legally responsible individual may
provide a PDS upon written approval from the department if:
(a) The individual submits to the department
a completed PDS Request Form for Immediate Family Member, Guardian, or Legally
Responsible Individual as a Paid Service Provider;
(b) The individual has unique abilities
necessary to meet the needs of the participant;
(c) The individual has obtained education,
job experience, volunteerism, or training beyond the direct care of the
participant;
(d) The services being
provided are not natural supports;
(e) The individual enables the participant to
be integrated in the community; and
(f)
1. The
nearest provider is more than thirty (30) miles from the participant's
residence; or
2. A qualified
provider cannot:
a. Provide the necessary
services according to the person-centered service plan; or
b. Accommodate the participant's
schedule.
(9) A service advisor through PDS
coordination shall:
(a) Advise a participant
regarding any aspect of PDS or blended services and facilitate access to
services;
(b) Provide information
for accessing assistance twenty-four (24) hours per day, seven (7) days per
week;
(c) Comply with all
applicable federal and state laws and requirements;
(d) Continually monitor a participant's
health, safety, and welfare and provide information on how to access
resources;
(e) Request a:
1. Copy of the participant's current
person-centered service plan; or
2.
Reassessment through the independent assessor; and
(f) Conduct at least one (1) face-to-face
visit:
1. With the participant
monthly;
2. With the participant
and the participant's representative, if the participant has a representative,
at least once every three (3) months; and
3. At the participant's residence at least
once every three (3) months.
(10) A participant shall be responsible for
all employer-related expenses and responsibilities.
(11) A PDS provider shall not provide more
than forty (40) hours of PDS in a calendar week (Sunday through
Saturday).
Section 8. Case Management Requirements.
(1) A case manager shall:
(a) Have:
1.
A bachelor's degree in a health or human services field from an accredited
college or university; and
2.
a. At least one (1) year of experience in a
health or human services field; or
b. The educational or experiential equivalent
in the field of aging or disabilities; or
(b) Be a registered nurse who has:
1. At least two (2) years of experience as a
professional nurse in the field of aging or disabilities; or
2. A master's degree in a health or human
services field from an accredited college or university.
(2) A case manager shall
be supervised by a case management supervisor who:
(a) Has at least four (4) years of experience
as a case manager in the field of aging or disabilities; and
(b) Meets the requirements established in
subsection (1) of this section.
(3) A case manager shall meet with a
participant, the participant's guardian, or the participant's legal
representative within seven (7) days of receiving a referral from an
independent assessor regarding the participant.
(4) A case manager shall:
(a) Communicate in a way that ensures the
best interest of the participant;
(b) Be able to identify and meet the needs of
the participant;
(c)
1. Be competent in the participant's language
either through personal knowledge of the language or through interpretation;
and
2. Demonstrate a heightened
awareness of the unique way in which the participant interacts with the world
around the participant;
(d) Ensure that:
1. The participant is educated in a way that
addresses the participant's:
a. Need for
knowledge of the case management process;
b. Personal rights; and
c. Risks and responsibilities as well as
awareness of available services; and
2. All individuals involved in implementing
the participant's person-centered service plan are informed of changes in the
scope of work related to the person-centered service plan as
applicable;
(e) Have a
code of ethics to guide the case manager in providing case management that
shall address:
1. Advocating for standards
that promote outcomes of quality;
2. Ensuring that no harm is done;
3. Respecting the rights of others to make
their own decisions;
4. Treating
others fairly; and
5. Being
faithful and following through on promises and commitments;
(f)
1. Lead the person-centered service planning
team; and
2. Take charge of
coordinating services through team meetings with representatives of all
agencies involved in implementing a participant's person-centered service
plan;
(g)
1. Include the participant's participation,
guardian's participation, or legal representative's participation in the case
management process; and
2. Make the
participant's preferences and participation in decision making a
priority;
(h) Document:
1. A participant's interactions and
communications with other agencies involved in implementing the participant's
person-centered service plan; and
2. Personal observations;
(i) Advocate for a participant
with service providers to ensure that services are delivered as established in
the participant's person-centered service plan;
(j) Be accountable to:
1. A participant to whom the case manager
provides case management in ensuring that the participant's needs are
met;
2. A participant's
person-centered team and provide leadership to the team and follow through on
commitments made; and
3. The case
manager's employer by following the employer's policies and
procedures;
(k) Stay
current regarding the practice of case management and case management
research;
(l) Assess the quality of
services, safety of services, and cost effectiveness of services being provided
to a participant in order to ensure that implementation of the participant's
person-centered service plan is successful and done so in a way that is
efficient regarding the participant's financial assets and benefits;
(m) Accurately reflect in the MWMA if a
participant is:
1. Terminated from the HCB
waiver program;
2. Admitted to a
hospital;
3. Admitted to a skilled
nursing facility;
4. Transferred to
another Medicaid 1915(c) home and community based waiver service program;
or
5. Relocated to a different
address; and
(n) Provide
information about participant-directed services to the participant,
participant's guardian, or participant's legal representative:
1. At the time the initial person-centered
service plan is developed; and
2.
At least annually thereafter and upon inquiry from the participant,
participant's guardian, or participant's legal representative.
(5)
(a) Case management for any individual who
begins receiving HCB waiver services shall be conflict free except as allowed
in paragraph (b) of this subsection.
(b)
1.
Conflict free case management shall be a scenario in which a provider including
any subsidiary, partnership, not-for-profit, or for-profit business entity that
has a business interest in the provider who renders case management to a
participant shall not also provide another 1915(c) home and community based
waiver service to that same participant unless the provider is the only willing
and qualified HCB waiver provider within thirty (30) miles of the participant's
residence.
2. An exemption to the
conflict free case management requirement shall be granted if:
a. A participant requests the
exemption;
b. The participant's
case manager provides documentation of evidence to the department that there is
a lack of a qualified case manager within thirty (30) miles of the
participant's residence;
c. The
participant or participant's representative and case manager signs a completed
MAP 531 Conflict-Free Case Management Exemption; and
d. The participant, participant's
representative, or case manager uploads the completed MAP 531 Conflict-Free
Case Management Exemption into the MWMA.
3. If a case management service is approved
to be provided despite not being conflict free, the case management provider
shall document conflict of interest protections, separating case management and
service provision functions within the provider entity and demonstrate that the
participant is provided with a clear and accessible alternative dispute
resolution process.
4. An exemption
to the conflict free case management requirement shall be requested upon
reassessment or at least annually.
(c) A participant who receives HCB waiver
services shall transition to conflict free case management when the
participant's next level of care determination occurs.
(d) During the transition to conflict free
case management, any case manager providing case management to a participant
shall educate the participant and members of the participant's person-centered
team of the conflict free case management requirement in order to prepare the
participant to decide, if necessary, to change the participant's:
1. Case manager; or
2. Provider of non-case management HCB waiver
services.
(e) If a
participant chooses a new case manager in order to comply with the conflict
free case management requirement, the new case manager and the participant's
assessment team shall be responsible for:
1.
Developing the material necessary for the participant's next level of care
determination;
2. Submitting the
material associated with the participant's next level of care determination to
the MWMA;
3. Developing the
participant's next person-centered service plan; and
4. Submitting the participant's next
person-centered service plan to the MWMA.
(6) Case management shall involve:
(a) A constant recognition of what is and is
not working regarding a participant; and
(b) Changing what is not working.
(7) A case manager shall:
(a) Arrange for a service but not provide a
service directly;
(b) Contact the
participant at least monthly by telephone or through a face-to-face visit with
a minimum of one (1) face-to-face visit between the case manager and the
participant:
1. Every other month in:
a. An adult day health care center;
or
b. The participant's residence;
and
2. At least three
(3) times a calendar year in the participant's residence;
(c) Ensure that services are provided in
accordance with the participant's person-centered service plan;
(d) Issue a participant corrective action
plan if:
1. The participant does not comply
with the person-centered service plan;
2. The participant, a family member of the
participant, an employee of the participant, the participant's guardian, or a
legal representative of the participant threatens, intimidates, or consistently
refuses services from any HCB waiver provider;
3. Imminent threat of harm to the
participant's health, safety, or welfare exists;
4. The participant, a family member of the
participant, an employee of the participant, the participant's guardian, or a
legal representative of the participant interferes with or denies the provision
of an assessment, case management, or service advisory; or
5. If the PDS provider does not comply with
the PDS provider requirements established in Section 6(1) of this
administrative regulation; and
(e) Issue a recommendation to the department
for termination from HCB waiver services or PDS if a participant corrective
action plan cannot be agreed upon or fulfilled by the participant,
participant's guardian, or participant's legal representative.