RELATES TO:
KRS
13B.010-13B.170,
194A.700(1),
(7),
205.010(6),
205.201,
205.203,
205.455-465,
209.030(2),
(3), 42 U.S.C. Chapter 35
NECESSITY, FUNCTION, AND CONFORMITY: 42 U.S.C. Chapter 35
authorizes grants to states to provide assistance in the development of new or
improved programs for older persons.
KRS
194A.050(1) authorizes the
secretary to promulgate administrative regulations necessary to implement
programs mandated by federal law, or to qualify for the receipt of federal
funds. KRS
205.204 designates the cabinet as the state
agency to administer 42 U.S.C. Chapter 35 in Kentucky and promulgate
administrative regulations for this purpose. This administrative regulation
establishes the standards of operation for a homecare program for elderly
persons in Kentucky.
Section 1.
Definitions.
(1) "Activities of daily living"
is defined by KRS
194A.700(1).
(2) "Area plan" means the plan that:
(a) Is submitted by a district for the
approval of the department; and
(b)
Releases funds under contract for the delivery of services within the planning
and service area.
(3)
"Assessment" means the collection and evaluation of information about a
person's situation and functioning to determine the applicant's or recipient's
service level and development of a plan of care utilizing a holistic,
person-[]centered approach by a qualified case manager.
(4) "Case management" means a process,
coordinated by a case manager, for linking a client to appropriate,
comprehensive, and timely home or community based services as identified in the
plan of care by:
(a) Planning;
(b) Referring;
(c) Monitoring;
(d) Advocating; and
(e) Following the timeline of the assessment
agency to obtain:
1. Service level;
and
2. Development of the plan of
care.
(5) "Case
management supervisor" means an individual:
(a) Meeting the requirements of Section
5(1)(a) of this administrative regulation; and
(b) Who has four (4) years or more experience
as a case manager.
(6)
"Case manager" means the individual employee responsible for:
(a) Coordinating services and supports from
all agencies involved in providing services required by the plan of
care;
(b) Completing the initial
assessment, plan of care, and annual reassessment;
(c) Ensuring all service providers have a
working knowledge of the plan of care; and
(d) Ensuring services are delivered as
required.
(7) "Case
record" means the collection of information, documents, demographics, and
required information maintained in the Aging Services tracking data
system.
(8) "Department" means the
Department for Aging and Independent Living.
(9) "District" is defined by
KRS
205.455(4).
(10) "Extraordinary out-of-pocket expenses"
means medical expenses not covered by insurance including:
(a) Copays;
(b) Deductibles;
(c) Prescriptions;
(d) Premiums for medical insurance;
or
(e) Other medical, dental, or
vision cost incurred as a result of medically necessary treatments or
procedures.
(11)
"Homecare services" means services that:
(a)
Are:
1. Provided to an eligible individual who
is a "functionally impaired elderly person" as defined by
KRS
205.455(7); and
2. Directed to the individual established in
subparagraph 1 of this paragraph toward:
a.
Prevention of unnecessary institutionalization; and
b. Maintenance in the least restrictive
environment, excluding residential facilities;
and
(b)
Include:
1. "Chore services" as defined by
KRS
205.455(1);
2. "Core services" as defined by
KRS
205.455(2);
3. "Escort services" as defined by
KRS
205.455(5);
4. "Home-delivered meals" as defined by
KRS
205.455(8);
5. "Home-health aide services" as defined by
KRS
205.455(9);
6. "Homemaker services" as defined by
KRS
205.455(10);
7. "Home repair services" as defined by
KRS
205.455(11);
8. "Personal care services" as defined by
subsection (16) of this section; and
9. "Respite services" as defined by
KRS
205.455(12).
(12) "Informal supports" means any care
provided to an individual that is not provided as part of a public or private
formal service program.
(13)
"Instrumental activities of daily living" is defined by
KRS
194A.700(7).
(14) "Natural Supports" means a non-paid
person or community resource who can provide, or has historically provided,
assistance to the consumer or, due to the familial relationship, would be
expected to provide assistance if capable.
(15) "Personal care services" means
assistance with activities of daily living.
(16) "Person-centered planning" means a
process:
(a) For selecting and organizing the
services and supports that an older adult or person with a disability might
need to live in the community and is directed by the person who receives the
support; and
(b) That is directed
by the person who receives the support.
(17) "Reassessment" means reevaluation of the
situation and functioning of a client.
(18) "Service level" means the minimum
contact required through face-to-face visits and telephone calls by the case
manager or social service assistant.
(19) "Social service assistant" means an
individual who:
(a) Has at least a high school
diploma or equivalent;
(b) Works
under the direction of the case manager supervisor;
(c) Assists the case manager with record
keeping, filing, data entry, and phone calls;
(d) Helps determine what type of assistance
their clients need;
(e) Assists the
client in getting services to carry out the plan of care;
(f) Coordinates services provided to the
client;
(g) Assists clients in
applying for other services or benefits for which they may qualify;
and
(h) Monitors clients to ensure
services are provided appropriately.
Section 2. Service Provider Responsibilities.
A service provider contracting with a district to provide homecare services
supported in whole or in part from funds received from the cabinet shall:
(1) Assure the provision of homecare services
throughout the geographic area covered under its plan or proposal;
(2) Review the provision of homecare services
to assure safety and consistency;
(3) Treat the client in a respectful and
dignified manner and involve the client and caregiver in the delivery of
homecare services;
(4) Allow staff
of the cabinet and the district to monitor and evaluate homecare services
provided;
(5) Assure that each paid
or voluntary staff member meets qualification and training standards
established for each specific service by the department;
(6) Maintain a written job description for
each paid staff and volunteer position involved in direct service
delivery;
(7) Develop and maintain
written personnel policies and a wage scale for each job classification;
and
(8) Designate a supervisor to
assure that staff providing homecare services are provided
supervision.
Section 3.
Homecare Plan. For program approval, a district shall submit to the cabinet a
proposal within its area plan to include at least:
(1) An assurance of access for the department
to records of the district pertaining to its contract for delivery of homecare
services; and
(2) A plan for the
delivery of homecare services in the area to be served by the district
containing:
(a) Identification of services
currently provided in the district; and
(b) The following assurances:
1. A justification of a decision not to fund
a homecare service, including an assurance of adequate availability from
another funding source;
2. A policy
and procedure for assuring a client's:
a.
Eligibility in accordance with Section 4 of this administrative regulation;
and
b. Implementation of case
management;
3. A policy
and procedure for a client's referral for service to other appropriate programs
and services as established in paragraph (a) of this subsection;
4. A policy and procedure for volunteer
programs to be utilized;
5.
Identification of a service provider for each specific service;
6. A policy and procedure for the periodic
monitoring of a client for the appropriateness of homecare services and to
assure safety and consistency by:
a. In home
visits; and
b. Review of records on
site and electronically;
7. A number of proposed clients for homecare
services to be provided directly or by contract;
8. A unit cost per service to be used as a
basis for determining an applicable percentage for the fee schedule as
established in Section 9(2) of this administrative regulation;
9. A policy and procedure for the acceptance
of a voluntary contribution and assurance the contribution shall be used to
maintain or increase the level of service;
10. A policy and procedure for the reporting
of abuse, neglect, and exploitation consistent with
KRS
209.030(2) and
(3);
11. A policy and procedure for the manner in
which delivery of homecare services shall be provided to an eligible
individual;
12. A policy and
procedure for monitoring a subcontract for delivery of direct homecare
services;
13. A policy and
procedure assuring that assessments and client information, as established in
Section 5(4) of this administrative regulation, shall include the following
information submitted electronically to the department in the formats
prescribed by the Aging Services Tracking System:
a. Demographic information, including family
income;
b. Physical
health;
c. Activities of daily
living and instrumental activities of daily living;
d. Physical environment;
e. Mental and emotional status;
f. Assistive devices, sensory impairment, and
communication abilities;
g. Formal
and informal resources; and
h.
Summary and judgment;
14.
A policy and procedure assuring that training shall be provided or requested
for issues found during sub-provider monitoring;
15. A policy and procedure for placing
clients on hold including:
a. Reasons the
individual is a client;
b. How
contact will be made while client is on hold;
c. Any exceptions to the hold policy;
and
d. Length of time a client may
be on hold; and
16. A
policy and procedure for termination or reduction of
services.
Section
4. Eligibility.
(1) A
prospective client for homecare services shall:
(a) Verify that the prospective client is a
person sixty (60) years of age or older;
(b) Not be eligible for the same or similar
services through Medicaid unless the individual is:
1. Considered inappropriate for person
directed services due to:
a. An inability to
manage the individual's own services; and
b. A lack of availability of a person to act
as the individual's representative; or
2. Unable to access the Home and Community
Based Waiver through a traditional provider; and
(c) Meet one (1) of the following criteria:
1. Be functionally impaired in the
performance of:
a. Two (2) activities of daily
living;
b. Three (3) instrumental
activities of daily living; or
c. A
combination of one (1) activity of daily living and two (2) instrumental
activities of daily living;
2. Have a stable medical condition requiring
skilled health services; or
3. Be:
a. Currently residing in:
(i) A skilled nursing facility;
(ii) An intermediate care facility;
or
(iii) A personal care facility;
and
b. Able to be
maintained at home if appropriate living arrangements and support systems are
established.
(2) Eligibility shall be determined by a case
manager who shall be qualified in accordance with Section 5(2) of this
administrative regulation.
(3) If a
client meets eligibility requirements of subsection (1) of this section for
homecare services, the client or caregiver shall be informed that the client
shall be eligible for services.
(4)
The case manager shall determine a prospective client's eligibility for:
(a)
1.
In-home services; or
2. Respite for
the unpaid primary caregiver; and
(b) Service level of case management as
determined on the DAIL-HC-01, Scoring Service Level.
(5)
(a) The
homecare program shall not supplant or replace services provided by the
client's natural support system.
(b) Except as established in paragraph (c) of
this subsection, if needs are being met by the natural support system, the
client shall be deemed ineligible.
(c) An applicant who needs respite services
shall not be deemed ineligible as a result of this subsection.
(6) An applicant who is eligible
for services and for whom funding is not available shall be placed on a waiting
list for services.
Section
5. Case Management Requirements.
(1) A district shall employ a case manager to
assess the eligibility and needs for each client and provide case
management.
(2) A case manager
shall:
(a) Meet one (1) of the following
qualifications:
1. Possess a minimum of a
bachelor's degree in at least one (1) of the following:
a. Social work;
b. Gerontology;
c. Psychology;
d. Sociology; or
e. A field related to geriatrics;
2. Possess a bachelor's degree in
nursing with a current Kentucky nursing license;
3. Possess:
a. A bachelor's degree in a field not related
to geriatrics with two (2) years of experience working with the elderly;
or
b. A master's degree in a human
services field, which shall substitute for the required experience;
4. Possess an associate's degree
in a health or family services field and two (2) years of experience working
with the elderly, which shall substitute for a bachelor's degree;
5. Be a Kentucky-registered nurse with a
current Kentucky license and two (2) years of experience working with the
elderly; or
6. Be a licensed
practical nurse with a current Kentucky license and three (3) years of
experience working with the elderly. and
(b) Be supervised by a case management
supervisor.
(3) Each
client shall be assigned a case manager.
(4) The case manager shall assess the
eligibility and needs of individuals:
(a)
Initially; and
(b) At least
annually thereafter.
(c) If the
client is ineligible, the case manager shall close the case, document the
reason in the case record, provide a list of potential resources, and notify
the client or caregiver by mail.
(5) Case management services shall not be
provided to individuals on a waiting list for homecare.
(6) The case manager shall:
(a) Be responsible for coordinating,
arranging, and documenting those services provided by:
1. Any funding source;
2. A volunteer; or
3. Formal or informal supports;
(b)
1. Make a reasonable effort to secure and
utilize informal supports for each client; and
2. Document the reasonable effort in the
client's case record;
(c)
Monitor each client by conducting a home visit according to the assessed
service level and through a telephone contact between home visits. Clients
shall be contacted at a minimum as follows:
1. Level 1, a home visit shall be conducted
every other month;
2. Level 2, a
home visit shall be conducted every four (4) months; and
3. Level 3, a home visit shall be conducted
every six (6) months;
(d)
Document in the case record each contact made with a client, as established in
paragraph (c) of this subsection, or on behalf of the client.
(e) Practice cultural humility with awareness
and respect for diversity and inclusion; and
(f) Provide a copy of the Rights and
Responsibilities form to the client, in his or her preferred language; and
1. Explain the rights and responsibilities to
the client; and
2. Document receipt
of form in the client record.,
(7) A social service assistant may be
assigned to Level 3 clients to assist with meeting the assessed
needs.
Section 6. Service
Planning.
(1) The client shall participate in
the assessment and development of a person-centered plan of care with the case
manager, natural supports, and other formal or informal service providers as
available.
(2) Upon the receipt of
a referral the case manager shall:
(a) Contact
the client or client's representative and schedule the initial
assessment;
(b) Perform the
assessment through:
1. Interviews with the
client, existing care givers, and natural supports;
2. Direct observation of the client's
abilities and deficits; and
3.
Discovery of the client's cultural preferences, practices, and
beliefs;
(c) Determine
the client's eligibility;
(d)
Document all activities and determinations in the case record;
(e) Meet with the person-centered planning
team and identify:
1. The assessed needs of
the client;
2. The services that
will address the identified needs; and
3. Goals that support the client's needs and
preferences; and
(f)
Compose the plan of care.
(3) The plan of care shall:
(a) Relate to an assessed problem;
(b) Identify a goal to be achieved;
(c) Identify a scope, duration, and unit of
service required;
(d) Identify a
source of service;
(e) Include a
plan for reassessment; and
(f) Be
signed by the client or client's representative and case manager, with a copy
provided to the client.
(4) The client shall be reassessed at least
annually, and more frequently if there is a documented change in status that
indicates a need for adjustment to the service level or plan of care.
Section 7. Quality Service. If a
client is determined eligible for homecare services, the case manager shall:
(1) Read, or have read and explained to the
client, the purpose of the DAIL - HC- 02, Quality Service Agreement;
(2) Document the client's acknowledgement of
receipt in the case record;
(3)
Maintain the original document in the client's case record;
(4) Provide a copy of the completed agreement
to the client. The copy shall contain the name, address, and telephone number
of:
(a) The current case manager;
(b) A designated representative of the
district; and
(c) A representative
of the department;
(5)
Inform the client of his or her right to file a complaint regarding services
and provide assistance as requested;
(6) Ensure that a copy of a DAIL - HC- 03,
Report of Complaint or Concern containing written complaints and detailed
reports of telephoned or verbal complaints, concerns or homecare service
suggestions is maintained in the client's case record and documented in a
centralized log;
(7) Keep the
identity of a complainant confidential; and
(8) Document investigation and efforts at
resolution or service improvement that shall be available for monitoring by the
district and department staff.
Section
8. Appeals. A client may request an informal dispute resolution or
an appeal.
(1) An informal dispute resolution
shall be limited to the denial, reduction, or termination of
services.
(2) An informal dispute
resolution shall not be accepted if services are unavailable due to:
(a) The program not having funding to provide
the services; or
(b) The individual
does not meeting the eligibility requirements pursuant to Section 4 of this
administrative regulation.
(3) A request for an informal dispute
resolution shall:
(a) Be submitted to the
department's homecare program coordinator within thirty (30) days following the
notification of an adverse decision; and
(b) Contain the:
1. Name, address, and telephone number of the
client;
2. Decision being
disputed;
3. Justification for the
dispute;
4. Documentation
supporting the dispute; and
5.
Signature of person requesting the dispute resolution.
(4) The dispute resolution shall
be heard by three (3) employees of the departments Division of Quality Living.
One (1) of whom shall be the division director or the division director's
designee.
(5) The complainant shall
be provided an opportunity to appear before the dispute resolution team to
present facts or concerns about the denial, reduction, or termination of
services.
(6) The dispute
resolution team shall inform the complainant, in writing, of the decision
resulting from the dispute resolution within ten (10) business days of the
review.
(7) A complainant may
request an appeal for an administrative hearing conducted in accordance with
KRS Chapter 13B:
(a) Within thirty (30)
calendar days of the notice regarding the results of the dispute
resolution;
(b) Within thirty (30)
calendar days of the notice regarding the adverse action by the cabinet;
or
(c) By submitting a written
request for appeal to the Office of the Ombudsman and Administrative Review,
Quality Advancement Branch, 275 E. Main St, 2 E-O, Frankfort, Kentucky
40621.
Section
9. Fees and Contributions.
(1)
The case manager shall be responsible for determining fee paying status, using
the criteria established in this subsection.
(a) A fee shall not be assessed for the
provision of assessment, case management services, or home-delivered
meals.
(b) The case manager shall:
1. Consider extraordinary out-of-pocket
expenses to determine a client's ability to pay; and
2. Document in a case record a waiver or
reduction of fee due to the extraordinary out-of-pocket expenses.
(c) A fee shall not be assessed to
an eligible individual who meets the definition of "needy aged" as defined by
KRS
205.010(6).
(d)
1. SSI
income or a food stamp allotment shall not be deemed available to other family
members.
2. The applicant receiving
SSI benefits or a food stamp allotment shall be considered a family of one (1)
for the purpose of fee determination.
(2) An eligible person shall be charged a fee
determined by the cost of the service unit multiplied by the applicable
percentage rate based upon income and size of family using 130 percent the
official poverty income guidelines published annually in the Federal Register
by the United States Department of Health and Human Services. Service unit cost
shall be determined by the state agency or contracting entity in accordance
with its contract. The copayment amount shall be based on the household's
percentage of poverty, as follows:
Percentage of Poverty
|
1 Person
|
2 Person
|
3 Person or More
|
0 - 129%
|
0%
|
0%
|
0%
|
130% - 149%
|
20%
|
0%
|
0%
|
150% - 169%
|
40%
|
20%
|
0%
|
170%-189%
|
60%
|
40%
|
20%
|
190%-209%
|
80%
|
60%
|
40%
|
210%-229%
|
100%
|
80%
|
60%
|
230%-249%
|
100%
|
100%
|
80%
|
250% and above
|
100%
|
100%
|
100%
|
(3)
(a) A contribution from an individual or
family with a zero percent copay shall be encouraged.
(b) Suggested contribution or donation rates
may be established, without pressure shall not be placed upon the client to
donate or contribute.
(c) Homecare
services shall not be withheld from an otherwise eligible individual based upon
the individual's failure to voluntarily contribute to support
services.
(4) The
district shall review and approve or deny, based on the contracted agency's
district policies, the procedure implemented by a service provider for the
collecting, accounting, spending, and auditing of fees and donations.
Section 10. Allocation Formula.
The homecare program funding formula shall consist of a $40,000 base for each
district, with the remaining amount of funds distributed in proportion to the
district's elderly (sixty (60) plus) population in the state.
Section 11. Termination or Reduction of
Homecare Services.
(1)
(a) A case manager or client may terminate or
reduce homecare services.
(b)
Homecare services shall be terminated if:
1.
The program can no longer safely meet the client's needs;
2. The client does not pay the copay for
services as established in Section 9(2) of this administrative
regulation;
3. The client refuses
to follow the plan of care; or
4.
a. The client or family member has exhibited
abusive, intimidating, or threatening behavior; and
b. The client or representative is unable or
unwilling to comply with the corrective action plan.
(2) Homecare services
may be reduced if:
(a) The client's condition
or support system improves;
(b)
Program funding has been reduced; or
(c) The client refuses to follow the plan of
care for a particular service.
(3) If homecare services are terminated or
reduced, the case manager shall:
(a) Inform
the client of the right to file a complaint;
(b) Notify the client or caregiver of the
action taken; and
(c) Assist the
client and family in making referrals to another agency if
applicable.
(4) If
homecare services are terminated or reduced due to reasons unrelated to the
client's needs or condition, the designated district representative in
conjunction with the case manager shall determine reduction or termination on a
case-by-case basis based on the requirements established in this administrative
regulation.
Section 12.
Incorporation by Reference.
(1) The following
material is incorporated by reference:
(a)
"DAIL-HC- 01, Scoring Service Level", 4/2014;
(b) "DAIL -HC- 02, Quality Service
Agreement", 4/2014;
(c) "DAIL -HC-
03, Report of Complaint or Concern", 4/2014; and
(d) "Rights and Responsibilities",
1/2023.
(2) This material
may be inspected, copied, or obtained, subject to applicable copyright law, at
Cabinet for Health and Family Services, 275 East Main Street, Frankfort,
Kentucky 40621, Monday through Friday, 8:00 a.m. to 4:30 p.m. This material may
also be viewed on the department's Web site at
https://chfs.ky.gov/agencies/dail/Pages/default.aspx.