Current through Register Vol. 50, No. 9, March 1, 2024
RELATES TO:
KRS
205.520(3),
205.5605,
205.5606,
205.5607,
205.635,
42 C.F.R.
440.180
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 provisions for home and community
based waiver services version 1, including participant-directed services
pursuant to KRS
205.5606.
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) "Assessment team" means a team that:
(a) Conducts assessment or reassessment
services; and
(b) Consists of:
1. Two (2) registered nurses; or
2. One (1) registered nurse and one (1) of
the following:
a. A certified social
worker;
b. A certified psychologist
with autonomous functioning;
c. A
licensed psychological practitioner;
d. A licensed marriage and family
therapist;
e. A licensed
professional clinical counselor;
f.
A licensed social worker; or
g. A
licensed clinical social worker.
(8) "Blended services" means a
non-duplicative combination of HCB waiver services identified in Section 5 of
this administrative regulation and PDS identified in Section 6 of this
administrative regulation provided pursuant to a recipient's approved plan of
care.
(9) "Budget allowance" is
defined by KRS
205.5605(1).
(10) "Certified psychologist with autonomous
functioning" or "licensed psychological practitioner" means a person licensed
pursuant to KRS Chapter 319.
(11)
"Certified social worker" means an individual who meets the requirements
established in KRS
335.080.
(12) "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.
(13) "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.
(14) "Covered services and supports" is
defined by KRS
205.5605(3).
(15) "DCBS" means the Department for
Community Based Services.
(16)
"Department" means the Department for Medicaid Services or its
designee.
(17) "Electronic
signature" is defined by
KRS
369.102(8).
(18) "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.
(19) "Home and community based waiver
services" or "HCB waiver services" means home and community based waiver
services:
(a) For individuals who meet the
requirements of Section 4 of this administrative regulation; and
(b) Covered by the department pursuant to
this administrative regulation.
(20) "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.
(21) "Home health agency" means an agency
that is:
(a) Licensed in accordance with
902 KAR 20:081; and
(b) Medicare and Medicaid
certified.
(22) "Illicit
drug" means:
(a) A drug, prescription or not
prescription, used illegally or in excess of therapeutic levels; or
(b) A prohibited drug.
(23) "Licensed clinical social worker" means
an individual who meets the requirements established in
KRS
335.100.
(24) "Licensed marriage and family therapist"
or "LMFT" is defined by
KRS
335.300(2).
(25) "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.
(26)
"Licensed professional clinical counselor" or "LPCC" is defined by
KRS
335.500(3).
(27) "Licensed social worker" means an
individual who meets the requirements established in
KRS
335.090.
(28) "Neglect" regarding:
(a) An adult is defined by
KRS
209.020(16); or
(b) A child means neglect pursuant to KRS
Chapter 600 or 620.
(29)
"NF" means nursing facility.
(30)
"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.
(31) "Normal baby-sitting" means general care
provided to a child that includes custody, control, and supervision.
(32) "Occupational therapist" is defined by
KRS
319A.010(3).
(33) "Occupational therapy assistant" is
defined by KRS
319A.010(4).
(34) "Participant" means a recipient who
meets the:
(a) NF level of care criteria
established in
907 KAR 1:022; and
(b) Eligibility criteria for HCB waiver
services established in Section 4 of this administrative regulation.
(35) "Patient liability" means the
financial amount an individual is required to contribute toward cost of care in
order to maintain Medicaid eligibility.
(36) "PDS" means participant-directed
services.
(37) "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.
(38)
"Physical therapist" is defined by
KRS
327.010(2).
(39) "Physical therapist assistant" means a
skilled health care worker who:
(a) Is
certified by the Kentucky Board of Physical Therapy; and
(b) Performs physical therapy and related
duties as assigned by the supervising physical therapist.
(40) "Physician assistant" or "PA" is defined
by KRS
311.840(3).
(41) "Plan of care" or "POC" means a written
individualized comprehensive plan that:
(a)
Encompasses all HCB waiver services; and
(b) Is developed by a participant or a
participant's legal representative, case manager, or other individual
designated by the participant.
(42) "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.
(43) "Prohibited drug" means a drug or
substance that is illegal under KRS Chapter 218A.
(44) "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.
(45)
"Representative" is defined by
KRS
205.5605(6).
(46) "Sex crime" is defined by
KRS
17.165(1).
(47) "Speech-language pathologist" is defined
by KRS
334A.020(3).
(48) "Support broker" means an individual
chosen by a participant from an agency designated by the department to:
(a) Provide training, technical assistance,
and support to a participant; and
(b) Assist a participant in any other aspects
of PDS.
(49) "Support
spending plan" means a plan for a participant that identifies the:
(a) PDS requested;
(b) Employee name;
(c) Hourly wage;
(d) Hours per month;
(e) Monthly pay;
(f) Taxes; and
(g) Budget allowance.
(50) "Violent crime" is defined by
KRS
17.165(3).
(51) "Violent offender" is defined by
KRS
17.165(2).
Section 2. Provider Participation.
(1) In order to provide HCB waiver services
version 1, excluding participant-directed services, an HCB waiver provider
shall be a home health agency or ADHC center that provides services:
(a) Directly; or
(b) Indirectly through a
subcontractor.
(2) An
out-of-state provider shall comply with the requirements of this administrative
regulation.
(3) An HCB waiver
provider:
(a) Shall comply with the following
administrative regulations and program requirements:
1.
902 KAR 20:081;
2.
907 KAR 1:671;
3.
907 KAR 1:672;
4.
907 KAR 1:673;
5. The Department for Medicaid Services Home
and Community Based Waiver Services Manual; and
6. The Department for Medicaid Services Adult
Day Health Care Services Manual;
(b) Shall not enroll a participant for whom
the provider cannot provide HCB waiver services;
(c) Shall choose to accept or not accept a
participant;
(d) Shall implement a
procedure to ensure that the following is reported:
1. Abuse, neglect, or exploitation of a
participant in accordance with KRS Chapters 209 or 620;
2. A slip or fall;
3. A transportation incident;
4. Improper administration of
medication;
5. A medical
complication; or
6. An incident
caused by the recipient, including:
a. Verbal
or physical abuse of staff or other recipients;
b. Destruction or damage of property;
or
c. Recipient self-abuse;
(e) Shall
ensure a copy of each incident report required by paragraph (d) of this
subsection is maintained in a central file subject to review by the
department;
(f) Shall implement a
process for communicating the incident, the outcome, and the prevention plan
to:
1. The participant, family member, or
responsible party; and
2. The
attending physician, PA, or APRN;
(g) Shall maintain documentation of any
communication provided in accordance with paragraph (f) of this subsection. The
documentation shall be:
1. Recorded in the
participant's case record; and
2.
Signed and dated by the staff member making the entry;
(h) Shall implement a procedure that ensures
the reporting of a participant or any interested party's complaint against the
provider or its personnel to the provider agency or facility;
(i) Shall ensure that a copy of each
complaint reported is maintained in a central file subject to review by the
department;
(j) Shall implement a
process for communicating a complaint, the resulting outcome, and related
prevention plan to:
1. The participant, family
member, or the participant's responsible party; and
2. The attending physician, PA, or APRN if
appropriate;
(k) Shall
maintain documentation of any communication provided in accordance with
paragraph (j) of this subsection. The documentation shall be:
1. Recorded in the participant's case record;
and
2. Signed and dated by the
staff member making the entry;
(l) Shall inform a participant or any
interested party in writing of the provider's:
1. Hours of operation; and
2. Policies and procedures;
(m) Shall not permit a staff
member who has contracted a communicable disease to provide a service to a
participant until the condition is determined to no longer be
contagious;
(n) Shall ensure that a
staff member who provides direct services:
1.
Demonstrates the ability to:
a.
Read;
b. Write;
c. Understand and carry out
instructions;
d. Keep simple
records; and
e. Interact with a
participant when providing an HCB waiver service;
2. Is trained by an HCB waiver provider;
and
3. Is supervised by an RN at
least every other month;
(o) Shall ensure that each staff person:
1. Prior to independently providing a direct
service, is trained regarding:
a. Abuse,
neglect, fraud, and exploitation;
b. The reporting of abuse, neglect, fraud,
and exploitation;
c.
Person-centered planning principles;
d. Documentation requirements; and
e. HCB services definitions and
requirements;
2.
Receives cardio pulmonary resuscitation certification and first aid
certification provided by a nationally accredited entity within six (6) months
of employment;
3. Maintains current
CPR certification and first aid certification for the duration of the staff
person's employment;
4.
a. Completes a tuberculosis (TB) risk
assessment performed by a licensed medical professional within the past twelve
(12) months and annually thereafter; and
b.
(i) If a
TB risk assessment resulted in a TB skin test being performed, have a negative
result within the past twelve (12) months as documented on test results
received by the provider within thirty (30) days of the date of hire;
and
(ii) If it is determined that
signs or symptoms of active disease are present, in order for the person to be
allowed to work, be administered follow-up testing by his or her physician or
physician assistant with the testing indicating the person does not have active
TB disease; and
5. Prior to the beginning of employment, has
successfully passed a drug test with no indication of prohibited or illicit
drug use;
(p)
1. Shall:
a.
Prior to hiring an individual, obtain:
(i) The
results of a criminal record check from the Kentucky Administrative Office of
the Courts and equivalent out-of-state agency if the individual resided or
worked outside of Kentucky during the twelve (12) months prior to
employment;
(ii) The results of a
Nurse Aide Abuse Registry check as described in
906 KAR 1:100 and an equivalent
out-of-state agency if the individual resided or worked outside of Kentucky
during the twelve (12) months prior to employment; and
(iii) The results of a Caregiver Misconduct
Registry check as described in
922 KAR 5:120 and equivalent
out-of-state agency if the individual resided or worked outside of Kentucky
during the twelve (12) months prior to employment; and
b. Within thirty (30) days of the date of
hire, obtain the results of a Central Registry check as described in
922 KAR 1:470 and an equivalent
out-of-state agency if the individual resided or worked outside of Kentucky
during the twelve (12) months prior to employment; or
2. May use Kentucky's national background
check program established by
906 KAR 1:190 to satisfy the
background check requirements of subparagraph 1 of this paragraph;
and
(q) Shall not allow
a staff person to provide HCB waiver services if the individual:
1. Has a prior conviction of or pled guilty
to a:
a. Sex crime; or
b. Violent crime;
2. Is a violent offender;
3. Has a prior felony conviction;
4. Has a drug related conviction, felony plea
bargain, or amended plea bargain conviction within the past five (5)
years;
5. Has a positive drug test
for an illicit or a prohibited drug;
6. Has a conviction of abuse, neglect, or
exploitation;
7. Has a Cabinet for
Health and Family Services finding of:
a.
Child abuse or neglect pursuant to the Central Registry as described in
922 KAR 1:470; or
b. Adult abuse, neglect, or exploitation
pursuant to the Caregiver Misconduct Registry as described in
922 KAR 5:120;
8. Is listed on the Nurse Aide
Abuse Registry pursuant to
906 KAR 1:100;
9. Within the twelve (12) months prior to
employment, is listed on or has a finding indicated on another state's
equivalent of the:
a. Nurse Aide Abuse
Registry as described in
906 KAR 1:100 if the other state
has an equivalent;
b. Caregiver
Misconduct Registry as described in
922 KAR 5:120 if the other state
has an equivalent; or
c. Central
Registry as described in
922 KAR 1:470 if the other state
has an equivalent; or
10. Has been convicted of Medicaid or
Medicare fraud.
Section 3. Maintenance of Records.
(1) An HCB waiver provider shall maintain:
(a) A clinical record for each participant.
The clinical record shall contain the following:
1. Pertinent medical, nursing, and social
history;
2. A comprehensive
assessment entered on form MAP-351, Medicaid Waiver Assessment and signed by
the:
a. Assessment team; and
b. Department;
3. A completed MAP 109, Plan of Care/Prior
Authorization for Waiver Services;
4. A copy of the MAP-350, Long Term Care
Facilities and Home and Community Based Program Certification Form signed by
the participant or participant's legal representative at the time of
application or reapplication and each recertification thereafter;
5. The name of the case manager;
6. Documentation of all level of care
determinations;
7. All
documentation related to prior authorizations, including requests, approvals,
and denials;
8. Documentation of
each contact with, or on behalf of, a participant;
9. Documentation that the participant
receiving ADHC services was provided a copy of the ADHC center's posted hours
of operation;
10. Documentation
that the participant or legal representative was informed of the procedure for
reporting complaints; and
11.
Documentation of each service provided that shall include:
a. The date the service was
provided;
b. The duration of the
service;
c. The arrival and
departure time of the provider, excluding travel time, if the service was
provided at the participant's home;
d. Itemization of each personal care or
homemaking service delivered;
e.
The participant's arrival and departure time, excluding travel time, if the
service was provided at the ADHC center;
f. Progress notes, which shall include
documentation of changes, responses, and treatments utilized to evaluate the
participant's needs; and
g. The
name, title, and signature of the service provider; and
(b)
1. Fiscal reports regarding services
provided, service records regarding services provided, and incident reports.
These reports shall be retained:
a. At least
six (6) years from the date that a covered service is provided; or
b. For a minor, three (3) years after the
recipient reaches the age of majority under state law, whichever is
longest.
2. If the
Secretary of the United States Department of Health and Human Services requires
a longer document retention period than the period referenced in subparagraph
1. of this paragraph, pursuant to
42 C.F.R.
431.17, the period established by the
secretary shall be the required period.
(2) Upon request, an HCB waiver provider
shall make information regarding service and financial records available to
the:
(a) Department;
(b) Cabinet for Health and Family Services,
Office of Inspector General or its designee;
(c) Department for Health and Human Services
or its designee;
(d) General
Accounting Office or its designee;
(e) Office of the Auditor of Public Accounts
or its designee; or
(f) Office of
the Attorney General or its designee.
Section 4. Participant Eligibility
Determinations and Redeterminations.
(1) An
HCB waiver service shall be provided to a Medicaid eligible participant who:
(a) Is determined by the department to meet
NF level of care requirements; and
(b) Would, without waiver services, be
admitted by a physician's order to an NF.
(2) The department shall perform an NF level
of care determination for each participant at least once every twelve (12)
months or more often if necessary.
(3) An HCB waiver service shall not be
provided to an individual who:
(a) Does not
require a service other than:
1. A minor home
adaptation;
2. Case management;
or
3. A minor home adaptation and
case management;
(b) Is
an inpatient of:
1. A hospital;
2. An NF; or
3. An intermediate care facility for
individuals with an intellectual disability;
(c) Is a resident of a licensed personal care
home; or
(d) Is receiving services
from another 1915(c) home and community based services waiver
program.
(4) An HCB
waiver provider shall:
(a) Inform a
participant or the participant's legal representative of the choice to receive:
1. HCB waiver services; or
2. Institutional services; and
(b) Require a participant to sign
a MAP-350, Long Term Care Facilities and Home and Community Based Program
Certification Form at the time of application or reapplication and at each
recertification to document that the individual was informed of the choice to
receive HCB waiver or institutional services.
(5) An eligible participant or the
participant's legal representative shall select a participating HCB waiver
provider from which the participant wishes to receive HCB waiver
services.
(6) An HCB waiver
provider shall use a MAP-24, Memorandum to notify the local DCBS office and the
department of a participant's:
(a) Termination
from the HCB waiver program; or
(b)
1. Admission to an NF for less than sixty
(60) consecutive days; and
2.
Return to the HCB waiver program from an NF within sixty (60) consecutive
days.
Section
5. Covered Services.
(1) An HCB
waiver service shall:
(a) Be prior authorized
by the department to ensure that the service or modification of the service
already meets the needs of the participant;
(b) Be provided pursuant to a plan of care
or, for a PDS, pursuant to a plan of care and support spending plan;
(c) Except for a PDS, not be provided by a
member of the participant's family. A PDS may be provided by a participant's
family member; and
(d) Be accessed
within sixty (60) days of the date of prior authorization.
(2) To request prior authorization, a
provider shall submit a completed MAP 10, Waiver Services Physician's
Recommendation; MAP 109, Plan of Care/Prior Authorization for Waiver Services;
and MAP 351, Medicaid Waiver Assessment to the department.
(3) Covered HCB services shall include:
(a) A comprehensive assessment, which shall:
1. Identify a participant's needs and the
services that the participant or the participant's family cannot manage or
arrange for on the participant's behalf;
2. Evaluate a participant's physical health,
mental health, social supports, and environment;
3. Be requested by an individual seeking HCB
waiver services or the individual's family, legal representative, physician,
physician assistant, or APRN;
4. Be
conducted by an assessment team within seven (7) calendar days of receipt of
the request for assessment; and
5.
Include at least one (1) face-to-face home visit by a member of the assessment
team with the participant and, if appropriate, the participant's
family;
(b) A
reassessment service, which shall:
1.
Determine the continuing need for HCB waiver services and, if appropriate,
PDS;
2. Be performed at least every
twelve (12) months;
3. Be conducted
using the same procedures used in an assessment service;
4. Not be retroactive; and
5. Be initiated by an HCB waiver provider or
support broker who shall:
a. Notify the
department no more than three (3) weeks prior to the expiration of the current
level of care certification to ensure that certification is consecutive;
and
b. Not be reimbursed for a
service provided during a period that a participant is not covered by a valid
level of care certification;
(c) A case management service, which shall:
1. Consist of coordinating the delivery of
direct and indirect services to a participant;
2. Be provided by a case manager who shall:
a. Be an RN, LPN, certified social worker,
certified psychologist with autonomous functioning, licensed psychological
practitioner, LMFT, licensed clinical social worker, licensed social worker, or
an LPCC;
b. Arrange for a service
but not provide a service directly;
c. Contact the participant monthly by
telephone or through a face-to-face visit at the participant's residence or in
the ADHC center, with a minimum of one (1) face-to-face visit between the case
manager and the participant every other month; and
d. Assure that service delivery is in
accordance with a participant's plan of care;
3. Not include a group conference;
and
4. Include development of a
plan of care that shall:
a. Be completed on
the MAP 109, Plan of Care/Prior Authorization for Waiver Services;
b. Reflect the needs of the
participant;
c. List goals,
interventions, and outcomes;
d.
Specify services needed;
e.
Determine the amount, frequency, and duration of services;
f. Provide for reassessment at least every
twelve (12) months;
g. Be developed
and signed by the assessment team, case manager, and participant or
participant's family; and
h. Be
submitted to the department no later than thirty (30) calendar days after
receiving the department's verbal approval of NF level of care;
(d) A homemaker
service, which shall consist of general household activities and shall be
provided:
1. By staff pursuant to Section
2(3)(m) and (n) of this administrative regulation; and
2. To a participant:
a. Who is functionally unable, but would
normally perform age-appropriate homemaker tasks; and
b. If the caregiver regularly responsible for
homemaker activities is temporarily absent or functionally unable to manage the
homemaking activities;
(e) A personal care service, which shall
consist of age-appropriate medically-oriented services and be provided:
1. By staff pursuant to Section 2(3)(m) and
(n) of this administrative regulation; and
2. To a participant:
a. Who does not need highly skilled or
technical care;
b. For whom
services are essential to the participant's health and welfare and not for the
participant's family; and
c. Who
needs assistance with age-appropriate activities of daily living;
(f) An attendant care
service, which shall consist of hands-on care that is:
1. Provided by staff pursuant to Section
2(3)(m) and (n) of this administrative regulation to a participant who:
a. Is medically stable but functionally
dependent and requires care or supervision twenty-four (24) hours per day;
and
b. Has a family member or other
primary caretaker who is employed and not able to provide care during working
hours;
2. Not of a
general housekeeping nature; and
3.
Not provided to a participant who is receiving any of the following HCB waiver
services:
a. Personal care;
b. Homemaker; or
c. ADHC;
(g) A respite care service, which shall be
short term care based on the absence or need for relief of the primary
caretaker and be:
1. Provided by staff
pursuant to Section 2(3)(m) and (n) of this administrative regulation who
provide services at a level that appropriately and safely meets the medical
needs of the participant in the following settings:
a. A participant's place of residence;
or
b. An ADHC center during posted
hours of operation;
2.
Provided to a participant who has care needs beyond normal
baby-sitting;
3. Used no less than
every six (6) months; and
4.
Provided in accordance with
902 KAR 20:066;
(h) A minor home adaptation
service, which shall be a physical adaptation to a home that is necessary to
ensure the health, welfare, and safety of a participant, and which shall:
1. Meet all applicable safety and local
building codes;
2. Relate strictly
to the participant's disability and needs;
3. Exclude an adaptation or improvement to a
home that has no direct medical or remedial benefit to the participant;
and
4. Be submitted on form MAP-95
Request for Equipment Form for prior authorization; or
(i) An ADHC service, which shall:
1. Except for a participant approved for an
ADHC service prior to May 1, 2003, 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 ancillary services in accordance
with 907 KAR 1:023, if ordered by a
physician, PA, or APRN in a participant's ADHC plan of treatment. Ancillary
services shall:
a. Consist of evaluations or
reevaluations for the purpose of developing a plan, which shall be carried out
by the participant or ADHC center staff;
b. Be reasonable and necessary for the
participant's condition;
c. Be
rehabilitative in nature;
d.
Include physical therapy provided by a physical therapist or physical therapist
assistant, occupational therapy provided by an occupational therapist or
occupational therapy assistant, or speech therapy provided by a speech-language
pathologist; and
e. Comply with the
physical, occupational, and speech therapy requirements established in
Technical Criteria for Reviewing Ancillary Services for Adults;
5. Include respite care services
pursuant to paragraph (g) of this subsection;
6. 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 physical therapist;
h. A physical therapist assistant;
i. An occupational therapist;
j. An occupational therapy
assistant;
k. A speech-language
pathologist;
l. A certified social
worker;
m. A licensed clinical
social worker;
n. A
nutritionist;
o. A health
aide;
p. An LPCC;
q. An LMFT;
r. A certified psychologist with autonomous
functioning;
s. A licensed
psychological practitioner; or
t. A
licensed social worker; and
7. Be provided pursuant to a plan of
treatment. The plan of treatment shall:
a. Be
developed and signed by each member of the plan of treatment team, which shall
include the participant or a legal representative of the participant;
b. Include pertinent diagnoses, mental
status, services required, frequency of visits to the ADHC center, prognosis,
rehabilitation potential, functional limitation, activities permitted,
nutritional requirements, medication, treatment, safety measures to protect
against injury, instructions for timely discharge, and other pertinent
information; and
c. Be developed
annually from information on the MAP 351, Medicaid Waiver Assessment and
revised as needed.
(4) Modification of an ancillary therapy
service or an ADHC unit of service shall require prior authorization as
established in this subsection.
(a) Prior
authorization shall:
1. Be requested by an RN
or designated ADHC center staff; and
2. Require submission of a revised MAP 109,
Plan of Care/Prior Authorization for Waiver Services and an order signed by a
physician, physician assistant, or APRN.
(b) An RN or designated ADHC center staff
shall forward a copy of the documents required in paragraph (a) of this
subsection to the HCB case manager or the participant's support broker for
inclusion in the participant's case records within ten (10) working days of the
prior authorization request.
(c)
Upon approval or denial of a prior authorization request, the department shall
provide written notification to the HCB agency, the ADHC center, and the
participant.
(d) The case manager
or support broker shall:
1. Inform the ADHC
center of approval or denial; and
2. Document the approval or denial in the
case record.
(5)
(a) An
ADHC center shall maintain a sign in and out log documenting the provision of
services to participants.
(b)
Documentation shall include:
1. The date the
service was provided;
2. The
duration of the service;
3. The
arrival and departure time of the participant;
4. A description of the service provided;
and
5. The title and signature of
the staff who provided the service.
Section 6. Participant-Directed Services.
(1) Covered services and supports provided to
a participant participating in PDS shall include:
(a) Home and community support services,
which shall:
1. Be available only under the
participant-directed services;
2.
Be provided in the participant's home or in the community;
3. Be based upon therapeutic goals and not be
divisional in nature; and
4. Not be
provided to a participant if the same or similar service is being provided to
the participant via non-PDS HCB waiver services; or
(b) Goods and services, which shall:
1. Be individualized;
2. Meet identified needs required by the
participant's plan of care that are necessary to ensure the health, welfare,
and safety of the participant;
3.
Be items or minor adaptations that are utilized to reduce the need for personal
care or to enhance independence within the home or community of the
participant;
4. Not include
experimental goods or services; and
5. Not include chemical or physical
restraints.
(2) To be covered, a PDS shall be specified
in the plan of care.
(3)
Reimbursement for a PDS shall not exceed the department's allowed reimbursement
for the same or similar service provided in a non-PDS HCB setting.
(4) A participant, including a married
participant, shall choose providers and a participant's choice shall be
reflected or documented in the plan of care.
(5)
(a) A
participant may designate a representative to act on the participant's
behalf.
(b) A PDS representative
shall:
1. Be twenty-one (21) years of age or
older;
2. Not be monetarily
compensated for acting as the PDS representative or providing a PDS;
3. Be appointed by the participant on a MAP
2000, Initiation/Termination of Consumer Directed Option (CDO)/Participant
Directed Services (PDS);
4. Comply
with the requirements for background and related checks established in Section
2(3)(p) of this administrative regulation; and
5. Not be a PDS representative if found in
violation of any of the provisions established in subsection (11)(i) of this
section.
(6)
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 support broker.
(7) The department shall immediately
terminate a participant from PDS if:
(a)
Imminent danger to the participant's health, safety, or welfare
exists;
(b) The participant fails
to pay patient liability;
(c) The
participant's plan of care 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; or
(d) The participant, caregiver, family, or
guardian threatens or intimidates a support broker or other PDS
staff.
(8) The
department may terminate a participant from PDS if it determines that the
participant's PDS provider has not adhered to the plan of care.
(9) Except for an immediate termination as
provided in subsection (7) of this section if a participant is to be terminated
from PDS, the support broker shall:
(a) Notify
the assessment or reassessment service provider of potential
termination;
(b) Assist the
participant in developing a resolution and prevention 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 PDS if the participant
fails to meet the requirements in paragraph (c) of this subsection;
and
(e) Assist the participant in
transitioning back to traditional HCB waiver services.
(10) Upon an involuntary termination of PDS,
the department shall:
(a) Notify a participant
in writing of its decision to terminate the participant's PDS participation;
and
(b) Except if a participant
failed to pay patient liability, inform the participant of the right to appeal
the department's decision in accordance with Section 9 of this administrative
regulation.
(11) A PDS
provider shall:
(a) Be selected by the
participant;
(b) Submit a completed
Kentucky Consumer Directed Options/Participant Directed Services
Employee/Provider Contract to the support broker;
(c) Be eighteen (18) years of age or
older;
(d) 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;
(e)
Be able to communicate effectively with the participant, participant
representative, or family;
(f) Be
able to understand and carry out instructions;
(g) Be able to keep records as required by
the participant;
(h) Submit to the
background and related checks established in Section 2(3)(p) of this
administrative regulation;
(i) Not
be a PDS provider excluded from providing services in accordance with Section
2(3)(q) of this administrative regulation;
(j) Prior to the beginning of employment,
complete training on the reporting of abuse, neglect, or exploitation in
accordance with KRS
209.030 or
620.030 and on the needs of the
participant;
(k) Comply with the TB
risk assessment and test requirements established in Section 2(3)(o)4 of this
administrative regulation;
(l)
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; and
(m)
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;
(n) Be
approved by the department;
(o)
Maintain and submit timesheets documenting hours worked; and
(p) Be a friend, spouse, parent, family
member, other relative, employee of a provider agency, or other person hired by
the participant.
(12) A
PDS provider shall not provide more than forty (40) hours of PDS in a calendar
week (Sunday through Saturday).
(13)
(a) The
department shall establish a budget for a participant based on the individual's
historical costs minus five (5) percent to cover costs associated with
administering the participant-directed services. If no historical cost exists
for the participant, the participant's budget shall equal the average per
capita, per service historical costs of HCB recipients minus five (5)
percent.
(b) Cost of services
authorized by the department for the participant's prior year plan of care but
not utilized may be added to the budget if necessary to meet the participant's
needs.
(c) The department shall
adjust a participant's budget based on the participant's needs and in
accordance with paragraphs (d) and (e) of this subsection.
(d) A participant's budget shall not be
adjusted to a level higher than established in paragraph (a) of this subsection
unless:
1. The participant's support broker
requests an adjustment to a level higher than established in paragraph (a) of
this subsection; and
2. The
department approves the adjustment.
(e) The department shall consider the
following factors in determining whether to allow for a budget adjustment:
1. If the proposed services are necessary to
prevent imminent institutionalization;
2. The cost effectiveness of the proposed
services;
3. Protection of the
participant's health, safety, and welfare; and
4. If a significant change has occurred in
the participant's:
a. Physical condition
resulting in additional loss of function or limitations to activities of daily
living and instrumental activities of daily living;
b. Natural support system; or
c. Environmental living arrangement resulting
in the participant's relocation.
(f) A participant's budget shall not exceed
the average per capital cost of services provided to individuals in an
NF.
(14) Unless approved
by the department pursuant to subsection (13)(b) through (e) of this section,
if a PDS is expanded to a point in which expansion necessitates a budget
allowance increase, the entire service shall only be covered via a traditional
(non-PDS) waiver service provider.
(15) A support broker shall:
(a) Provide any needed assistance to a
participant with any aspect of PDS or blended services;
(b) Be available to a participant 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
(e) Complete or revise a plan of care using
the person-centered planning principles established in Person Centered
Planning: Guiding Principles.
(16)
(a) For
a PDS participant, a support broker may conduct an assessment or reassessment;
and
(b) A PDS assessment or
reassessment performed by a support broker shall comply with the assessment or
reassessment provisions established in Section 5(3)(a) and (b) of this
administrative regulation.
Section 8. Applicability and Transition to
HCB Waiver Version 2.
(1) The provisions and
requirements established in this administrative regulation shall:
(a) Apply to HCB waiver services provided to
an HCB waiver service recipient until the recipient transitions to the HCB
waiver version 2; and
(b) Not apply
to individuals receiving HCB waiver services version 2 pursuant to
907 KAR 7:010.
(2) An HCB waiver recipient
receiving services pursuant to this administrative regulation shall transition
to receiving services pursuant to
907 KAR 7:010 upon the
recipient's next level-of-care determination if the determination confirms that
the individual is eligible for HCB waiver services version 2.
(3)
(a) The
provisions and requirements established in this administrative regulation shall
become null and void at the time that the next level-of-care determination has
been performed regarding each participant currently receiving services via this
administrative regulation.
(b) Next
level-of-care determinations shall occur in accordance with
907 KAR 7:010, Section
4(2).
Section 10. Incorporation by Reference.
(1) The following material is incorporated by
reference:
(a) "Department for Medicaid
Services Adult Day Health Care Services Manual", May 2005;
(b) "Department for Medicaid Services Home
and Community Based Waiver Services Manual", September 2006;
(c) "Person Centered Planning: Guiding
Principles", March 2005;
(d)
"Technical Criteria for Reviewing Ancillary Services for Adults", November
2003;
(e) "MAP-24, Memorandum",
August 2008;
(f) "MAP-95 Request
for Equipment Form" June 2007;
(g)
"MAP 109, Plan of Care/Prior Authorization for Waiver Services", July
2008;
(h) "MAP-350, Long Term Care
Facilities and Home and Community Based Program Certification Form", July
2008;
(i) "MAP-351, Medicaid Waiver
Assessment", July 2015;
(j) "MAP
2000, Initiation/Termination of Consumer Directed Option (CDO)/Participant
Directed Services (PDS)", June 2015;
(k) "MAP-10, Waiver Services Physician's
Recommendation", June 2015; and
(l)
Kentucky Consumer Directed Options/Participant Directed Services
Employee/Provider Contract, June 2015.
(2) This material may be inspected, copied,
or obtained, subject to applicable copyright law, at the Department for
Medicaid Services, 275 East Main Street, Frankfort, Kentucky 40621, Monday
through Friday, 8 a.m. to 4:30 p.m.
STATUTORY AUTHORITY:
KRS
194A.030(2),
194A.050(1),
205.520(3),
205.5606,
42 C.F.R.
440.180,
42 U.S.C.
1396a,
1396b,
1396d,
1396n