Oklahoma Administrative Code
Title 317 - Oklahoma Health Care Authority
Chapter 30 - Medical Providers-Fee for Service
Subchapter 5 - Individual Providers and Specialties
Part 85 - ADVANTAGE PROGRAM WAIVER SERVICES
Section 317:30-5-763 - Description of services
Universal Citation: OK Admin Code 317:30-5-763
Current through Vol. 42, No. 1, September 16, 2024
Services included in the ADvantage program are:
(1) Case management.
(A) Case management services, regardless of
payment source, assist a member to gain access to medical, social, educational,
or other services that may benefit him or her to maintain health and safety.
Case managers:
(i) Initiate and oversee
necessary assessments and reassessments to establish or reestablish waiver
program eligibility;
(ii) Develop
the member's comprehensive person-centered service plan, listing only the
services necessary to prevent institutionalization of the member, as determined
through the assessments;
(iii)
Initiate the addition of necessary services or deletion of unnecessary
services, as dictated by the member's condition and available support;
and
(iv) Monitor the member's
condition to ensure delivery and appropriateness of services and initiate
person-centered service plan reviews. Case managers submit an individualized
Services Backup Plan, on all initial service plans, annually at reassessment,
and on updates as appropriate throughout the year, reflecting risk factors and
measures in place to minimize risks. When a member requires hospital or nursing
facility (NF) services, the case manager:
(I)
Assists the member in accessing institutional care and, as appropriate,
periodically monitors the member's progress during the institutional
stay;
(II) Helps the member
transition from institution to home by updating the person-centered service
plan;
(III) Prepares services to
start on the date the member is discharged from the institution; and
(IV) Must meet ADvantage program minimum
requirements for qualification and training prior to providing services to
ADvantage members.
(B) Providers of ADvantage services for the
member or for those who have an interest in or are employed by an ADvantage
provider for the member must not provide case management or develop the
person-centered service plan, except when the ADvantage Administration (AA)
demonstrates the only willing and qualified entity to provide case management
and/or develop person-centered service plans in a geographic area, also
provides other ADvantage services. Prior to providing services to members
receiving Consumer Directed Personal Assistance Services and Supports
(CD-PASS), case manager supervisors, and case managers are required to receive
training and demonstrate knowledge regarding the CD-PASS service delivery
model, "Independent Living Philosophy," and demonstrate competency in
person-centered planning.
(C)
Providers may only claim time for billable case management activities,
described as:
(i) Any task or function, per
Oklahoma Administrative Code (OAC)
317:30-5-763(1)(A)
that only an ADvantage case manager, because of skill, training, or authority,
can perform on behalf of a member; and
(ii) Ancillary activities, such as clerical
tasks, including, but not limited to, mailing, copying, filing, faxing, driving
time, or supervisory and administrative activities are not billable case
management activities. The administrative cost of these activities and other
normal and customary business overhead costs are included in the reimbursement
rate for billable activities.
(D) Case management services are prior
authorized and billed per fifteen (15) minute unit of service using the rate
associated with the location of residence of the member served.
(i) Case management services are billed using
a standard rate for reimbursement for billable service activities provided to a
member who resides in a county with a population density greater than
twenty-five (25) persons per square mile.
(ii) Case management services are billed
using a very rural/outside providers' service area rate for billable service
activities provided to a member who resides in a county with a population
density equal to, or less than twenty-five (25) persons per square mile.
Exceptions are services to members who reside in Oklahoma Human Services
(OKDHS) Community Living, Aging and Protective Services identified zip codes in
Osage County adjacent to the metropolitan areas of Tulsa and Washington
counties. Services to these members are prior authorized and billed using the
standard rate.
(iii) The latest
United States Census, Oklahoma counties population data is the source for
determination of whether a member resides in a county with a population density
equal to, or less than twenty-five (25) persons per square mile or resides in a
county with a population density greater than twenty-five (25) persons per
square mile.
(2) Respite.
(A) Respite services are provided to members
who are unable to care for themselves. Services are provided on a short-term
basis due to the primary caregiver's absence or need for relief. Payment for
respite care does not include room and board costs unless more than seven (7)
hours are provided in a NF. Respite care is only utilized when other sources of
care and support are exhausted. Respite care is only listed on the service plan
when it is necessary to prevent institutionalization of the member. Units of
services are limited to the number of units approved on the service
plan.
(B) In-home respite services
are billed per fifteen (15) minute unit of service. Within any one (1) day
period, a minimum of eight (8) units [two (2) hours] must be provided with a
maximum of twenty-eight (28) units [seven (7) hours] provided. The service is
provided in the member's home.
(C)
Facility-based extended respite is filed for a per diem rate when provided in a
NF. Extended respite must be at least eight (8) hours in duration.
(D) In-home extended respite is filed for a
per diem rate. A minimum of eight (8) hours must be provided in the member's
home.
(3) Adult day health (ADH) care.
(A) ADH is
furnished on a regularly scheduled basis for one (1) or more days per week in
an outpatient setting. It provides both health and social services necessary to
ensure the member's optimal functioning. Most assistance with activities of
daily living (ADLs), such as eating, mobility, toileting, and nail care are
integral to the ADH care service and are covered by the ADH care basic
reimbursement rate.
(B) ADH care is
a fifteen (15) minute unit of service. No more than eight (8) hours,
[thirty-two (32) units] are authorized per day. The number of units of service
a member may receive is limited to the number of units approved on the member's
approved service plan.
(C)
Physical, occupational, and speech therapies are only provided as an
enhancement to the basic ADH care service when authorized by the service plan
and are billed as a separate procedure. ADH care therapy enhancement is a
maximum of one (1) session unit per day of service.
(D) Meals provided as part of this service do
not constitute a full nutritional regimen. One (1) meal, that contains at least
one-third (1/3) of the current daily dietary recommended intake (DRI), as
established by the Food and Nutrition Board of the National Academies of
Sciences, Engineering, and Medicine, is provided to those participants who are
in the center for four (4) or more hours per day and does not constitute a full
nutritional regimen. Member's access to food at any time must also be available
in addition to the required meal and is consistent with an individual not
receiving Medicaid-funded services and supports.
(E) Personal care service enhancement in ADH
is assistance in bathing, hair care, or laundry service, authorized by the
person-centered service plan and billed as separate procedures. This service is
authorized when an ADvantage waiver member who uses ADH requires assistance
with bathing, hair care, or laundry to maintain health and safety. Assistance
with bathing, hair care, or laundry is not a usual and customary ADH care
service. ADH personal care enhancement is a maximum of one (1) unit per day of
bathing, hair care, or laundry service.
(F) OKDHS Home and Community-Based Services
(HCBS) waiver settings have qualities defined in Home and Community-Based
Services: Waiver Requirements, 42 Code of Federal Regulations, Section (§)
441.301 (c)(4) based on the individual's needs, defined in the member's
authorized service plan.
(i) The ADH center
is integrated and supports full access of ADvantage members to the greater
community, including opportunities to:
(I)
Seek employment and work in competitive integrated ADH Center, not a
requirement for persons that are retirement age;
(II) Engage in community life;
(III) Control personal resources;
and
(IV) Receive services in the
community, to the same degree as individuals not receiving ADvantage Program or
other Medicaid HBCS waiver services.
(ii) The ADH is selected by the member from
all available service options and given the opportunity to visit and understand
the options.
(iii) The ADH ensures
the member's rights of privacy, dignity, respect, and freedom from coercion and
restraint.
(iv) The ADH optimizes
the member's initiative, autonomy, and independence in making life choices
including, but not limited to:
(I) Daily
activities;
(II) The physical
environment; and
(III) Social
interactions.
(v) The ADH
facilitates the member's choice regarding services and supports including the
provider.
(vi) Each member has the
freedom and support to control his or her own schedules, activities, and access
to food at any time.
(vii) Each
member may have visitors whenever he or she chooses.
(viii) The ADH center is physically
accessible to the member.
(G) ADH centers that are presumed not to be
HCBS settings per 42 C.F.R.
§
441.301(c)(5)(v)
include, ADH centers:
(i) In a publicly- or
privately-owned facility providing inpatient treatment;
(ii) On the grounds of or adjacent to a
public institution; and
(iii) With
the effect of isolating individuals from the broader community of individuals
not receiving ADvantage program or another Medicaid HCBS;
(H) When the ADH is presumed not HCBS,
according to 42 C.F.R.
§
441.301(c)(5)(v), it
may be subject to heightened scrutiny by AA, the Oklahoma Health Care Authority
(OHCA), and the Centers for Medicare and Medicaid Services (CMS). The ADH must
provide evidence that the ADH portion of the facility has clear administrative,
financial, programmatic, and environmental distinctions from the institution
and comply with additional monitoring by the AA.
(4) Environmental modifications.
(A) Environmental modifications are physical
adaptations to the home, required by the member's person-centered service plan
that are necessary to ensure the member's health, welfare, and safety or enable
the member to function with greater independence in the home, and that without
such, the member would require institutionalization. Adaptations or
improvements to the home not of direct medical or remedial benefit to the
waiver member are excluded.
(B) All
services require prior authorization.
(5) Specialized medical equipment and supplies.
(A) Specialized medical
equipment and supplies are devices, controls, or appliances specified in the
person-centered service plan that enable members to increase their abilities to
perform ADLs, or to perceive, control, or communicate with the environment in
which they live. Necessary items for life support, ancillary supplies, and
equipment necessary for the proper functioning of such items, and durable and
non-durable medical equipment not available under the Oklahoma Medicaid State
Plan are also included. This service excludes any equipment or supply items not
of direct medical or remedial benefit to the waiver member and necessary to
prevent institutionalization.
(B)
Specialized medical equipment and supplies are billed using the appropriate
HealthCare Common Procedure Code (HCPC). Reoccurring supplies shipped and
delivered to the member are compensable only when the member remains eligible
for waiver services, continues to reside in the home, and is not
institutionalized in a hospital, skilled nursing facility, or nursing home. It
is the provider's responsibility to verify the member's status prior to
shipping and delivering these items. Payment for medical supplies is limited to
the SoonerCare (Medicaid) rate when established, to the Medicare rate, or to
actual acquisition cost, plus thirty percent (30%). All services must have
prior authorization.
(6) Advanced supportive/restorative assistance.
(A) Advanced supportive/restorative
assistance services are maintenance services used to assist a member who has a
chronic, yet stable condition. These services assist with ADLs that require
devices and procedures related to altered body functions. These services are
for maintenance only and are not utilized as treatment services.
(B) Advanced supportive/restorative
assistance service is billed per fifteen (15) minute unit of service. The
number of units of service a member may receive is limited to the number of
units approved on the person-centered service plan.
(7) Nursing.
(A) Nursing services are services listed in
the person-centered service plan that are within the scope of the state's Nurse
Practice Act. These services are provided by a registered nurse (RN), a
licensed practical nurse (LPN), or a licensed vocational nurse (LVN) under the
supervision of an RN licensed to practice and in good standing in the state in
which services are provided. Nursing services may be provided on an
intermittent or part-time basis or may be comprised of continuous care. The
provision of the nursing service works to prevent or postpone the
institutionalization of the member.
(B) Nursing services are services of a
maintenance or preventative nature provided to members with stable, chronic
conditions. These services are not intended to treat an acute health condition
and may not include services reimbursable under either the Medicaid or Medicare
home health program. This service primarily provides nurse supervision to the
personal care assistant or to the advanced supportive/restorative assistance
aide and assesses the member's health and prescribed medical services to ensure
they meet the member's needs as specified in the person-centered service plan.
A nursing assessment/evaluation, on-site visit is made to each member, with
additional visits for members with advanced supportive/restorative assistance
services authorized to evaluate the condition of the member and medical
appropriateness of services. An assessment/evaluation report is forwarded to
the ADvantage program case manager and the skilled nurse in accordance with
review schedule determined between the case manager and the skilled nurse and
outlined in the member's person-centered service plan, to report the member's
condition or other significant information concerning each ADvantage member.
(i) The ADvantage program case manager may
recommend authorization of nursing services as part of the interdisciplinary
team planning for the member's person-centered service plan and/or
assessment/evaluation of the:
(I) Member's
general health, functional ability, and needs; and/or
(II) Adequacy of personal care and/or
advanced supportive/restorative assistance services to meet the member's needs,
including providing on-the-job training and competency testing for personal
care or advanced supportive/restorative care aides per rules and regulations
for the delegation of nursing tasks established by the Board of Nursing in the
state in which services are provided.
(ii) In addition to assessment/evaluation,
the ADvantage program case manager may recommend authorization of nursing
services to:
(I) Prepare a one (1) week
supply of insulin syringes for a person who is blind and has diabetes and can
safely self-inject the medication but cannot fill his or her own syringe. This
service includes monitoring the member's continued ability to self-administer
the insulin;
(II) Prepare oral
medications in divided daily compartments for a member who self-administers
prescribed medications but needs assistance and monitoring due to a minimal
level of disorientation or confusion;
(III) Monitor a member's skin condition when
a member is at risk for skin breakdown due to immobility or incontinence or the
member has a chronic stage II decubitus ulcer requiring maintenance care and
monitoring;
(IV) Provide nail care
for a member with diabetes or who has circulatory or neurological compromise;
and
(V) Provide consultation and
education to the member, member's family, or other informal caregivers
identified in the person-centered service plan, regarding the nature of the
member's chronic condition. Skills training, including return skills
demonstration to establish competency, to the member, family, or other informal
caregivers as specified in the person-centered service plan for preventive and
rehabilitative care procedures are also provided.
(C) Nursing service includes
interdisciplinary team planning and recommendations for the member's
person-centered service plan development and/or assessment/evaluation or for
other services within the scope of the nurse's license, including private duty
nursing. Nursing services are billed per fifteen (15) minute unit of service. A
specific procedure code is used to bill for interdisciplinary team planning and
recommendations for the member's person-centered service plan, but other
procedure codes may be used to bill for all other authorized nursing services.
A maximum of eight (8) units [two (2) hours], per day of nursing for service
plan development and assessment evaluation are allowed. An agreement by a
provider to perform a nurse evaluation is also an agreement to provide the
Medicaid in-home care services for which the provider is certified and
contracted. Reimbursement for a nurse evaluation is denied when the provider
that produced the nurse evaluation fails to provide the nurse assessment
identified in the Medicaid in-home care services for which the provider is
certified and contracted.
(8) Skilled nursing services.
(A) Skilled nursing services are listed in
the person-centered service plan, within the state's Nurse Practice Act scope,
and are ordered by a licensed physician, osteopathic physician, physician
assistant, or advanced practice nurse, and are provided by a RN, LPN, or LVN
under the supervision of a RN, licensed to practice and in good standing in the
state where services are provided. Skilled nursing services provided in the
member's home or other community setting are services requiring the specialized
skills of a licensed nurse. The scope and nature of these services are intended
for treatment of a disease or a medical condition and are beyond the scope of
ADvantage nursing services. These intermittent nursing services are targeted
toward a prescribed treatment or procedure that must be performed at a specific
time or other predictable rate of occurrence. The RN contacts the member's
physician to obtain necessary information or orders pertaining to the member's
care. When the member has an ongoing need for service activities requiring more
or less units than authorized, the RN must recommend, in writing, that the
service plan be revised.
(B)
Skilled nursing services are provided on an intermittent or part-time basis,
and billed per fifteen (15) minute unit of service. Skilled nursing services
are provided when nursing services are not available through Medicare or other
sources or when SoonerCare plan nursing services limits are exhausted. Amount,
frequency, and duration of services are prior-authorized in accordance with the
member's person-centered service plan.
(9) Home-delivered meals.
(A) Home-delivered meals provide one (1) meal
per day. A home-delivered meal is a meal prepared in advance and brought to the
member's home. Each meal must have a nutritional content equal to at least
one-third (1/3) of the dietary reference intakes as established by the Food and
Nutrition Board of the National Academies of Sciences, Engineering and
Medicine. Home-delivered meals are only provided to members who are unable to
prepare meals and lack an informal provider to do meal preparation.
(B) Home-delivered meals are billed per meal,
with one (1) meal equaling one (1) unit of service. The limit of the number of
units a member is allowed to receive is in accordance with the member's
person-centered service plan. The provider must obtain a signature from the
member or the member's representative at the time the meal is delivered. In the
event the member is temporarily unavailable, such as at a doctor's appointment,
and the meal is left at the member's home, the provider must document the
reason a signature was not obtained. The signature logs must be available for
review.
(10) Occupational therapy services.
(A) Occupational therapy services are
services that increase functional independence by enhancing the development of
adaptive skills and performance capacities of members with physical
disabilities and related psychological and cognitive impairments. Services are
provided in the member's home and are intended to help the member achieve
greater independence, enabling him or her to reside and participate in the
community. Treatment involves the therapeutic use of self-care, work, and play
activities, and may include modification of the tasks or environment to enable
the member to achieve maximum independence, prevent further disability, and
maintain health. Under a physician's order, a licensed occupational therapist
evaluates the member's rehabilitation potential and develops an appropriate
written, therapeutic regimen. The regimen utilizes paraprofessional,
occupational therapy assistant services, within the limitations of his or her
practice, working under the supervision of a licensed occupational therapist.
The regimen includes education and training for informal caregivers to assist
with or maintain services when appropriate. The occupational therapist ensures
monitoring and documentation of the member's rehabilitative progress and
reports to the member's case manager and physician to coordinate the necessary
addition or deletion of services, based on the member's condition and ongoing
rehabilitation potential.
(B)
Occupational therapy services are billed per fifteen (15) minute unit of
service. Payment is not allowed solely for written reports or record
documentation.
(11) Physical therapy services.
(A)
Physical therapy services are those services that maintain or improve physical
disability through the evaluation and rehabilitation of members disabled by
pain, disease, or injury. Services are provided in the member's home and are
intended to help the member achieve greater independence to reside and
participate in the community. Treatment involves the use of physical
therapeutic means, such as massage, manipulation, therapeutic exercise, cold
and/or heat therapy, hydrotherapy, electrical stimulation, and light therapy.
Under a physician's order, a licensed physical therapist evaluates the member's
rehabilitation potential and develops an appropriate, written, therapeutic
regimen. Under the Oklahoma Physical Therapy Practice Act, a physical therapist
may evaluate a member's rehabilitation potential and develop and implement an
appropriate, written, therapeutic regimen without a referral from a licensed
health care practitioner for a period not to exceed thirty (30) calendar days.
Any treatment required after the thirty (30) calendar day period requires a
prescription from a physician or the physician's assistant of the licensee. The
regimen utilizes paraprofessional physical therapy assistant services, within
the limitations of his or her practice, working under the licensed physical
therapist's supervision. The regimen includes education and training for
informal caregivers to assist with and/or maintain services when appropriate.
The licensed physical therapist ensures monitoring and documentation of the
member's rehabilitative progress and reports to the member's case manager and
physician to coordinate the necessary addition or deletion of services, based
on the member's condition and ongoing rehabilitation potential.
(B) Physical therapy services may be
authorized as ADH care therapy enhancement and are a maximum of one (1) session
unit per day of service. Payment is not allowed solely for written reports or
record documentation.
(12) Speech and language therapy services.
(A) Speech and language
therapy services are those that maintain or improve speech and language
communication and swallowing disorders/disability through the evaluation and
rehabilitation of members disabled by pain, disease, or injury. Services are
provided in an ADH service setting and are intended to help the member achieve
greater independence to reside and participate in the community. Services
involve the use of therapeutic means, such as evaluation, specialized
treatment, or development and oversight of a therapeutic maintenance program.
Under a physician's order, a licensed speech and language pathologist evaluates
the member's rehabilitation potential and develops an appropriate, written,
therapeutic regimen. The regimen utilizes speech language pathology assistant
services within the limitations of his or her practice, working under the
supervision of the licensed speech and language pathologist. The regimen
includes education and training for informal caregivers to assist with and/or
maintain services when appropriate. The speech and language pathologist ensures
monitoring and documentation of the member's rehabilitative progress and
reports to the member's case manager and physician to coordinate the necessary
addition and/or deletion of services, based on the member's condition and
ongoing rehabilitation potential.
(B) Speech and language therapy services are
authorized as ADH care-therapy enhancement and are a maximum of one (1) session
unit per day of service. Payment is not allowed solely for written reports or
record documentation.
(13) Hospice services.
(A) Hospice services are palliative and
comfort care provided to the member and his or her family when a physician
certifies the member has a terminal illness, with a life expectancy of six (6)
months or less, and orders hospice care. ADvantage hospice care is authorized
for a six (6) month period and requires physician certification of a terminal
illness and orders of hospice care. When the member requires more than six (6)
months of hospice care, a physician or nurse practitioner must have a
face-to-face visit with the member thirty (30) calendar days prior to the
initial hospice authorization end-date, and re-certify that the member has a
terminal illness, has six (6) months or less to live, and orders additional
hospice care. After the initial authorization period, additional periods of
ADvantage hospice may be authorized for a maximum of sixty (60) calendar day
increments with physician certification that the member has a terminal illness
and six (6) months or less to live. A member's person-centered service plan
that includes hospice care must comply with Waiver requirements to be within
total person-centered service plan cost limits.
(B) A hospice program offers palliative and
supportive care to meet the special needs arising out of the physical,
emotional, and spiritual stresses experienced during the final stages of
illness, through the end of life, and bereavement. The member signs a statement
choosing hospice care instead of routine medical care with the objective to
treat and cure the member's illness. Once the member has elected hospice care,
the hospice medical team assumes responsibility for the member's medical care
for the illness in the home environment. Hospice care services include nursing
care, physician services, medical equipment and supplies, drugs for symptom and
pain relief, home health aide and personal care services, physical,
occupational and speech therapies, medical social services, dietary counseling,
and grief and bereavement counseling to the member and/or the member's
family.
(C) A hospice
person-centered service plan must be developed by the hospice team in
conjunction with the member's ADvantage case manager before hospice services
are provided. The hospice services must be related to the palliation or
management of the member's terminal illness, symptom control, or to enable the
member to maintain ADL and basic functional skills. A member who is eligible
for Medicare hospice provided as a Medicare Part A benefit, is not eligible to
receive ADvantage hospice services.
(D) Hospice services are billed per diem of
service for days covered by a hospice person-centered service plan and while
the hospice provider is responsible for providing hospice services as needed by
the member or member's family. The maximum total annual reimbursement for a
member's hospice care within a twelve (12) month period is limited to an amount
equivalent to eighty-five percent (85%) of the Medicare hospice cap payment,
and must be authorized on the member's person-centered service
plan.
(14) ADvantage personal care.
(A)
ADvantage personal care is assistance to a member in carrying out ADLs, such as
bathing, grooming, and toileting or in carrying out instrumental activities of
daily living (IADLs), such as preparing meals and laundry service, to ensure
the member's personal health and safety, or to prevent or minimize physical
health regression or deterioration. Personal care services do not include
service provision of a technical nature, such as tracheal suctioning, bladder
catheterization, colostomy irrigation, or the operation and maintenance of
equipment of a technical nature.
(B) ADvantage home care agency skilled
nursing staff working in coordination with an ADvantage case manager is
responsible for the development and monitoring of the member's personal care
services.
(C) ADvantage personal
care services are prior-authorized and billed per fifteen (15) minute unit of
service, with units of service limited to the number of units on the ADvantage
approved person-centered service plan.
(15) Personal emergency response system (PERS).
(A) PERS is an electronic
device that enables members at high risk of institutionalization, to secure
help in an emergency. Members may also wear a portable "help" button to allow
for mobility. PERS is connected to the person's phone and programmed to signal,
per member preference, a friend, relative, or a response center, once the
"help" button is activated. For an ADvantage member to be eligible for PERS
service, the member must meet all service criteria in (i) through (vi). The
member:
(i) Has a recent history of falls as
a result of an existing medical condition that prevents the member from getting
up unassisted from a fall;
(ii)
Lives alone and without a regular caregiver, paid or unpaid, and therefore is
left alone for long periods of time;
(iii) Demonstrates the capability to
comprehend the purpose of and activate the PERS;
(iv) Has a health and safety plan detailing
the interventions beyond the PERS to ensure the member's health and safety in
his or her home;
(v) Has a disease
management plan to implement medical and health interventions that reduce the
possibility of falls by managing the member's underlying medical condition
causing the falls; and
(vi) Will
likely avoid premature or unnecessary institutionalization as a result of
PERS.
(B) PERS services
are billed using the appropriate HCPC procedure code for installation, monthly
service, or PERS purchase. All services are prior authorized per the ADvantage
approved service plan.
(16) CD-PASS.
(A) CD-PASS are personal services assistance
(PSA) and advanced personal services assistance (APSA) that enables a member in
need of assistance to reside in his or her home and community of choice, rather
than in an institution; and to carry out functions of daily living, self-care,
and mobility. CD-PASS services are delivered as authorized on the
person-centered service plan. The member becomes the employer of record and
employs the PSA and the APSA. The member is responsible, with assistance from
ADvantage program administrative Financial Management Services (FMS), for
ensuring the employment complies with state and federal labor law requirements.
The member/employer may designate an adult family member or friend, who is not
a PSA or APSA to the member, as an "authorized representative" to assist in
executing the employer functions. The member/employer:
(i) Recruits, hires, and, as necessary,
discharges the PSA or APSA;
(ii)
Ensures the PSA or APSA has received sufficient instruction and training. If
needed, the member/employer will work with the consumer-directed agent/case
manager (CDA) to obtain training assistance from ADvantage skilled nurses.
Prior to performing an APSA task for the first time, the APSA must demonstrate
competency in the tasks in an on-the-job training session conducted by the
member, and the member must document the attendant's competency in performing
each task in the APSA's personnel file;
(iii) Determines where and how the PSA or
APSA works, hours of work, what is to be accomplished and, within individual
budget allocation limits, wages to be paid for the work;
(iv) Supervises and documents employee work
time; and
(v) Provides tools and
materials for work to be accomplished.
(B) The services the PSA may provide include:
(i) Assistance with mobility and transferring
in and out of bed, wheelchair, or motor vehicle, or all;
(ii) Assistance with routine bodily
functions, such as:
(I) Bathing and personal
hygiene;
(II) Dressing and
grooming; and
(III) Eating,
including meal preparation and cleanup;
(iii) Assistance with home services, such as
shopping, laundry, cleaning, and seasonal chores;
(iv) Companion assistance, such as letter
writing, reading mail, and providing escort or transportation to participate in
approved activities or events. "Approved activities or events," means
community, civic participation guaranteed to all citizens including, but not
limited to, exercise of religion, voting or participation in daily life
activities in which exercise of choice and decision making is important to the
member, and may include shopping for food, clothing, or other necessities, or
for participation in other activities or events specifically approved on the
person-centered service plan.
(C) An APSA provides assistance with ADLs to
a member with a stable, chronic condition, when such assistance requires
devices and procedures related to altered body function if such activities, in
the opinion of the attending physician or licensed nurse, may be performed if
the member were physically capable, and the procedure may be safely performed
in the home. Services provided by the APSA are maintenance services and are
never used as therapeutic treatment. Members who develop medical complications
requiring skilled nursing services while receiving APSA services are referred
to his or her attending physician, who may order home health services, as
appropriate. APSA includes assistance with health maintenance activities that
may include:
(i) Routine personal care for
persons with ostomies, including tracheotomies, gastrostomies, and colostomies
with well-healed stoma, external, indwelling, and suprapubic catheters that
include changing bags and soap and water hygiene around the ostomy or catheter
site;
(ii) Removing external
catheters, inspecting skin, and reapplication of same;
(iii) Administering prescribed bowel program,
including use of suppositories and sphincter stimulation, and enemas
pre-packaged only without contraindicating rectal or intestinal
conditions;
(iv) Applying medicated
prescription lotions or ointments and dry, non-sterile dressings to unbroken
skin;
(v) Using a lift for
transfers;
(vi) Manually assisting
with oral medications;
(vii)
Providing passive range of motion (non-resistive flexion of joint) therapy,
delivered in accordance with the person-centered service plan unless
contraindicated by underlying joint pathology;
(viii) Applying non-sterile dressings to
superficial skin breaks or abrasions; and
(ix) Using universal precautions as defined
by the Centers for Disease Control and Prevention.
(D) FMS are program administrative services
provided to participating CD-PASS members/employers by AA. FMS are
employer-related assistance that provides Internal Revenue Service (IRS) fiscal
reporting agent and other financial management tasks and functions, including,
but not limited to:
(i) Processing employer
payroll, after the member/employer has verified and approved the employee time
sheet, at a minimum of semi-monthly, and associated withholding for taxes, or
for other payroll with holdings performed on behalf of the member as employer
of the PSA or APSA;
(ii) Other
employer-related payment disbursements as agreed to with the member/employer
and in accordance with the member/employer's individual budget
allocation;
(iii) Responsibility
for obtaining criminal and abuse registry background checks on prospective
hires for PSA or APSA on the member/employer's behalf;
(iv) Providing orientation and training
regarding employer responsibilities, as well as employer information and
management guidelines, materials, tools, and staff consultant expertise to
support and assist the member to successfully perform employer-related
functions; and
(v) Making Hepatitis
B vaccine and vaccination series available to PSA and APSA employees in
compliance with Occupational Safety and Health Administration (OSHA)
standards.
(E) The PSA
service is billed per fifteen (15) minute unit of service. The number of units
of PSA a member may receive is limited to the number of units approved on the
person-centered service plan.
(F)
The APSA service is billed per fifteen (15) minute unit of service. The number
of units of APSA a member may receive is limited to the number of units
approved on the person-centered service plan.
(17) Institution transition services.
(A) Institution transition
services are those services necessary to enable a member to leave the
institution and receive necessary support through ADvantage waiver services in
his or her home and community.
(B)
Transitional case management services are services per OAC
317:30-5-763(1)
required by the member and included on the member's person-centered service
plan that are necessary to ensure the member's health, welfare, and safety, or
to enable the member to function with greater independence in the home, and
without which, the member would continue to require institutionalization.
ADvantage transitional case management services assist institutionalized
members who are eligible to receive ADvantage services in gaining access to
needed waiver and other State Plan services, as well as needed medical, social,
educational, and other services to assist in the transition, regardless of the
funding source for the services to which access is gained. Transitional case
management services may be authorized for periodic monitoring of an ADvantage
member's progress during an institutional stay and for assisting the member to
transition from institution to home by updating the person-centered service
plan, including necessary institution transition services to prepare services
and supports to be in place or to start on the date the member is discharged
from the institution. Transitional case management services may be authorized
to assist individuals that have not previously received ADvantage services, but
were referred by CAP to the case management provider for assistance in
transitioning from the institution to the community with ADvantage services
support.
(i) Institution transition case
management services are prior authorized and billed per fifteen (15) minute
unit of service using the appropriate HCPC procedure code and modifier
associated with the location of residence of the member served, per OAC
317:30-5-763(1)(D).
(ii) A unique modifier code is used to
distinguish institution transitional case management services from regular case
management services.
(C)
Institution transition services may be authorized and reimbursed, per the
conditions in (i) through (iv).
(i) The
service is necessary to enable the member to move from the institution to his
or her home.
(ii) The member is
eligible to receive ADvantage services outside of the institutional
setting.
(iii) Institution
transition services are provided to the member within one-hundred and eighty
(180) calendar-days of discharge from the institution.
(iv) Services provided while the member is in
the institution are claimed as delivered on the day of discharge from the
institution.
(D) When the
member receives institution transition services but fails to enter the waiver,
any institution transition services provided are not
reimbursable.
(18) Assisted living services (ALS).
(A) ALS are personal care and supportive
services furnished to waiver members who reside in a homelike,
non-institutional setting that includes twenty-four (24) hour on-site response
capability to meet scheduled or unpredictable member needs and to provide
supervision, safety, and security. Services also include social and
recreational programming and medication assistance, to the extent permitted
under State law. The ALS provider is responsible for coordinating services
provided by third parties to ADvantage members in the assisted living center
(ALC). Nursing services are incidental rather than integral to the provision of
ALS. ADvantage reimbursement for ALS includes services of personal care,
housekeeping, laundry, meal preparation, periodic nursing evaluations, nursing
supervision during nursing intervention, intermittent or unscheduled nursing
care, medication administration, assistance with cognitive orientation,
assistance with transfer and ambulation, planned programs for socialization,
activities, and exercise, and for arranging or coordinating transportation to
and from medical appointments. Services, except for planned programs for
socialization, activities, and exercise, are to meet the member's specific
needs as determined through the individualized assessment and documented on the
member's person-centered service plan.
(B) The ADvantage ALS philosophy of service
delivery promotes member choice, and to the greatest extent possible, member
control. A member has control over his or her living space and his or her
choice of personal amenities, furnishings, and activities in the residence. The
ADvantage member must have the freedom to control his or her schedule and
activities. The ALS provider's documented operating philosophy, including
policies and procedures, must reflect and support the principles and values
associated with the ADvantage assisted living philosophy and approach to
service delivery emphasizing member dignity, privacy, individuality, and
independence.
(C) ADvantage ALS
required policies for admission and termination of services and definitions.
(i) ADvantage-certified assisted living
centers (ALC) are required to accept all eligible ADvantage members who choose
to receive services through the ALC, subject only to issues relating to, one
(1) or more of the following:
(I) Rental unit
availability;
(II) The member's
compatibility with other residents;
(III) The center's ability to accommodate
residents who have behavior problems, wander, or have needs that exceed the
services the center provides; or
(IV) Restrictions initiated by statutory
limitations.
(ii) The ALC
may specify the number of units the provider is making available to service
ADvantage members. At minimum, the ALC must designate ten (10) residential
units for ADvantage members. Residential units designated for ADvantage may be
used for other residents at the ALC when there are no pending ADvantage members
for those units. Exceptions may be requested in writing subject to the approval
of AA.
(iii) Mild or moderate
cognitive impairment of the applicant is not a justifiable reason to deny ALC
admission. Centers are required to specify whether they are able to accommodate
members who have behavior problems or wander. Denial of admission due to a
determination of incompatibility must be approved by the case manager and the
AA. Appropriateness of placement is not a unilateral determination by the ALC.
The ADvantage case manager, the member, or member's designated representative,
and the ALC in consultation determine the appropriateness of
placement.
(iv) The ALC is
responsible for meeting the member's needs for privacy, dignity, respect, and
freedom from coercion and restraint. The ALC must optimize the member's
initiative, autonomy, and independence in making life choices. The ALC must
facilitate member choices regarding services and supports, and who provides
them. Inability to meet those needs is not recognized as a reason for
determining an ADvantage member's placement is inappropriate. The ALC agrees to
provide or arrange and coordinate all services listed in the Oklahoma State
Department of Health (OSDH) regulations, per OAC
310:663-3-3, except for
specialized services.
(v) In
addition, the ADvantage participating ALC agrees to provide or coordinate the
services listed in (I) through (III).
(I)
Provide an emergency call system for each participating ADvantage
member.
(II) Provide up to three
(3) meals per day plus snacks sufficient to meet nutritional requirements,
including modified special diets, appropriate to the member's needs and
choices; and provide members with twenty-four (24) hour access to food by
giving members control in the selection of the foods they eat, by allowing the
member to store personal food in his or her room, by allowing the member to
prepare and eat food in his or her room, and allowing him or her to decide when
to eat.
(III) Arrange or coordinate
transportation to and from medical appointments. The ALC must assist the member
with accessing transportation for integration into the community, including
opportunities to seek employment and work in competitive integrated settings,
engage in community life, and control his or her personal resources and receive
services in the community to the same degree of access as residents not
receiving ADvantage services.
(vi) The provider may offer any specialized
service or rental unit for members with Alzheimer's disease and related
dementias, physical disabilities, or other special needs the facility intends
to market. Heightened scrutiny, through additional monitoring of the ALC by AA,
is utilized for those ALC's that also provide inpatient treatment; settings on
the grounds of or adjacent to a public institution and/or other settings that
tend to isolate individuals from the community. The ALC must include evidence
that the ALC portion of the facility has clear administrative, financial,
programmatic and environmental distinctions from the institution.
(vii) When the provider arranges and
coordinates services for members, the provider is obligated to ensure the
provision of those services.
(viii)
Per OAC 310:663-1-2, "personal care" is
defined as "assistance with meals, dressing, movement, bathing or other
personal needs or maintenance, or general supervision of the physical and
mental well-being of a person [Title 63 of the Oklahoma Statutes (O.S.),
Section (§) 1-1902.17] and includes assistance with toileting." For
ADvantage ALS, assistance with "other personal needs" in this definition
includes assistance with grooming and transferring. The term "assistance" is
clarified to mean hands-on help, in addition to supervision.
(ix) The specific ALS assistance provided
along with amount and duration of each type of assistance is based upon the
member's assessed need for service assistance and is specified in the ALC's
service plan that is incorporated as supplemental detail into the ADvantage
comprehensive person-centered service plan. The ADvantage case manager in
cooperation with ALC professional staff, develops the person-centered service
plan to meet member needs. As member needs change, the person-centered service
plan is amended consistent with the assessed, documented need for change in
services.
(x) Placement, or
continued placement of an ADvantage member in an ALC, is inappropriate when any
one (1) or more of the conditions in I through IV exist.
(I) The member's needs exceed the level of
services the center provides. Documentation must support ALC efforts to provide
or arrange for the required services to accommodate participant
needs.
(II) The member exhibits
behaviors or actions that repeatedly and substantially interfere with the
rights or well-being of other residents, and the ALC documented efforts to
resolve behavior problems including medical, behavioral, and increased staffing
interventions. Documentation must support the ALC's attempted interventions to
resolve behavior problems.
(III)
The member has a complex, unstable, or unpredictable medical condition and
treatment cannot be developed and implemented appropriately in the assisted
living environment. Documentation must support the ALC's attempts to obtain
appropriate member care.
(IV) The
member fails to pay room and board charges or OKDHS determined vendor payment
obligation.
(xi)
Termination of residence ensues when in appropriately placed. Once a
determination is made that a member is inappropriately placed, the ALC must
inform the member, the member's representative, if applicable, the AA, and the
member's ADvantage case manager. The ALC must develop a discharge plan in
consultation with the member, the member's representative, the ADvantage case
manager, and the AA. The ALC and case manager must ensure the discharge plan
includes strategies for providing increased services, when appropriate, to
minimize risk and meet the higher care needs of members transitioning out of
the ALC, when the reason for discharge is inability to meet member needs. When
voluntary termination of residency is not arranged, the ALC must provide
written notice to the member and to the member's representative, with a copy to
the member's ADvantage case manager and the AA. The written notice provides
intent to terminate the residency agreement and move the member to an
appropriate care provider. The thirty (30) calendar-day requirement must not
apply when emergency termination of the residency agreement is mandated by the
member's immediate health needs or when the termination of the residency
agreement is necessary for the physical safety of the member or other ALC
residents. The written involuntary termination of residency notice for reasons
of inappropriate placement must include:
(I)
A full explanation of the reasons for the termination of residency;
(II) The notice date;
(III) The date notice was given to the member
and the member's representative, the ADvantage case manager, and the
AA;
(IV) The date the member must
leave ALC; and
(V) Notification of
appeal rights and the process for submitting appeal of termination of Medicaid
ALS to OHCA.
(D) ADvantage ALS provider standards in
addition to licensure standards.
(i)
Physical environment.
(I) The
ALC must provide lockable doors on the entry door of each rental unit and an
attached, lockable compartment within each member unit for valuables. Members
must have exclusive rights to his or her unit with lockable doors at the
entrance of the individual or shared rental unit. Keys to rooms may be held by
only appropriate ALC staff as designated by the member's choice. Rental units
may be shared only when a request to do so is initiated by the member. Members
must be given the right to choose his or her roommate.
(II) The member has a legally enforceable
agreement, or lease, with the ALC. The member must have the same
responsibilities and protections from eviction as all tenants under the
landlord-tenant law of the state, county, city, or other designated entity.
(III) The ALC must provide each
rental unit with a means for each member to control the temperature in the
residential unit through the use of a damper, register, thermostat, or other
reasonable means under the control of the member and that preserves privacy,
independence, and safety, provided that the OSDH may approve an alternate means
based on documentation that the design of the temperature control is
appropriate to the special needs of each member who has an alternate
temperature control.
(IV) For ALCs
built prior to January 1, 2008, each ALC individual residential unit must have
a minimum total living space, including closets and storage areas, of
two-hundred and fifty (250) square feet; for ALCs built after December 31,
2007, each ALC individual residential unit must have a minimum total living
space, including closets and storage areas, of three-hundred and sixty (360)
square feet.
(V) The ALC must
provide a private bathroom for each living unit that must be equipped with one
(1) lavatory, one (1) toilet, and one (1) bathtub or shower stall.
(VI) The ALC must provide at a minimum; a
kitchenette, defined as a space containing a refrigerator, adequate storage
space for utensils, and a cooking appliance. A microwave is an acceptable
cooking appliance.
(VII) The member
is responsible for furnishing the rental unit. When a member is unable to
supply basic furnishings defined as a bed, dresser, nightst and, chairs, table,
trash can, and lamp, or if furnishings pose a health or safety risk, the
member's ADvantage case manager in coordination with the ALC, must assist the
member in obtaining basic furnishings for the rental unit. The member must have
the freedom to furnish and decorate the rental unit within the scope of the
lease or residency agreement.
(VIII) The ALC must meet the requirements of
all applicable federal and state laws and regulations including, but not
limited to, state and local sanitary codes, state building and fire safety
codes, and laws and regulations governing use and access by persons with
disabilities.
(IX) The ALC must
ensure the design of common areas accommodates the special needs of the
resident population and that the rental unit accommodates the special needs of
the member in compliance with the Americans with Disabilities Act accessibility
guidelines per Nondiscrimination on the Basis of Disability By Public
Accommodations and in in Commercial Facilities, 28 Code of Federal Regulations,
Appendix A, at no additional cost to the member.
(X) The ALC must provide adequate and
appropriate social and recreational space for residents and the common space
must be proportionate to the number of residents and appropriate for the
resident population.
(XI) The ALC
must provide appropriately monitored outdoor space for resident use.
(XII) The ALC must provide the member with
the right to have visitors of his or her choosing at any time. Overnight
visitation is allowed as permissible by the Landlord/Tenant
Agreement.
(XIII) The ALC must be
physically accessible to members.
(ii)
Sanitation.
(I) The ALC must maintain the facility,
including its individual rental units in a clean, safe, and sanitary manner,
ensuring that they are insect and rodent free, odorless, and in good repair at
all times.
(II) The ALC must
maintain buildings and grounds in a good state of repair, in a safe and
sanitary condition, and in compliance with the requirements of applicable
regulations, bylaws, and codes.
(III) The ALC stores clean laundry in a
manner that prevents contamination and changes linens at time intervals
necessary to avoid health issues.
(IV) The ALC must provide housekeeping in
member rental units to maintain a safe, clean, and sanitary
environment.
(V) The ALC must have
policies and procedures for members' pets.
(iii)
Health and safety.
(I) The ALC must provide building security
that protects members from intruders with security measures appropriate to
building design, environmental risk factors, and the resident
population.
(II) The ALC must
respond immediately and appropriately to missing members, accidents, medical
emergencies, or deaths.
(III) The
ALC must have a plan in place to prevent, contain, and report any diseases
considered to be infectious or are listed as diseases that must be reported to
the OSDH.
(IV) The ALC must adopt
policies for the prevention of abuse, neglect, and exploitation that include
screening, training, prevention, investigation, protection during
investigation, and reporting.
(V)
The ALC must provide services and facilities that accommodate the needs of
members to safely evacuate in the event of fires or other
emergencies.
(VI) The ALC must
ensure staff is trained to respond appropriately to emergencies.
(VII) The ALC must ensure that fire safety
requirements are met.
(VIII) The
ALC must offer meals that provide balanced and adequate nutrition for
members.
(IX) The ALC must adopt
safe practices for meal preparation and delivery.
(X) The ALC must provide a twenty-four (24)
hour response to personal emergencies appropriate to the needs of the resident
population.
(XI) The ALC must
provide safe transportation to and from ALC sponsored social or recreational
outings.
(iv)
Staff
to resident ratios.
(I) The ALC must
ensure a sufficient number of trained staff are on duty, awake, and present at
all times, twenty-four (24) hours a day, and seven (7) days a week, to meet
residents' needs and to carry out all processes listed in the ALC's written
emergency and disaster preparedness plan for fires and other
disasters.
(II) The ALC must ensure
staffing is sufficient to meet ADvantage program members' needs in accordance
with each member's ADvantage person-centered service plan.
(III) The ALC must have plans in place to
address situations where there is a disruption to the ALC's regular work
force.
(v)
Staff
training and qualifications.
(I) The
ALC must ensure staff has qualifications consistent with their job
responsibilities.
(II) All staff
assisting in, or responsible for, food service must have attended a food
service training program offered or approved by OSDH.
(III) The ALC must provide staff orientation
and ongoing training to develop and maintain staff knowledge and skills. All
direct care and activity staff receive at least eight (8) hours of orientation
and initial training within the first month of employment and at least four (4)
hours annually thereafter. Staff providing direct care on a dementia unit must
receive four (4) additional hours of dementia specific training. Annual first
aid and cardiopulmonary resuscitation (CPR) certification do not count toward
the four (4) hours of annual training.
(vi)
Staff supervision.
(I) The ALC must ensure delegation of tasks
to non-licensed staff is consistent and in compliance with all applicable state
regulations including, but not limited to, the state's Nurse Practice Act and
OSDH Nurse Aide Certification rules.
(II) The ALC must ensure that, where the
monitoring of food intake or therapeutic diets is provided at the prescribed
services level, a registered dietitian monitors member health and nutritional
status.
(vii)
Resident rights.
(I) The ALC
must provide to each member and each member's representative, at the time of
admission, a copy of the resident statutory rights listed in 63 O.S. §
1-1918 amended to include
additional rights and the clarification of rights as listed in the ADvantage
member assurances. A copy of resident rights must be posted in an easily
accessible, conspicuous place in the facility. The facility must ensure that
staff is familiar with and observes, the resident rights.
(II) The ALC must conspicuously post for
display in an area accessible to residents, employees, and visitors, the ALC's
complaint procedures and the name, address, and phone number of a person
authorized to receive complaints. A copy of the complaint procedure must also
be given to each member, the member's representative, or the legal guardian.
The ALC must ensure all employees comply with the ALC's complaint
procedure.
(III) The ALC must
provide to each member and member's representative, at the time of admission,
information about Medicaid grievance and appeal rights, including a description
of the process for submitting a grievance or appeal of any decision that
decreases Medicaid services to the member.
(viii)
Incident reporting.
(I) The ALC must maintain a record of
incidents that occur and report incidents to the member's ADvantage case
manager and to the AA, utilizing the AA Critical Incident Reporting form.
Incident reports are also made to Adult Protective Services (APS) and to the
OSDH, as appropriate, per ALC licensure rules, utilizing the specific reporting
forms required.
(II) Incidents
requiring report by licensed ALC's are those defined by OSDH, per OAC
310:663-19-1 and listed on the AA
Critical Incident Reporting form.
(III) Reports of incidents must be made to
the member's ADvantage case manager and to the AA via electronic submission
within one (1) business day of the reportable incident's discovery utilizing
the AA Critical Incident Reporting form. When required, a follow-up report of
the incident must be submitted via electronic submission to the member's
ADvantage case manager and to the AA. The follow-up report must be submitted
within five (5) business days of the incident. The final report must be filed
with the member's ADvantage case manager and the AA when the investigation is
complete, not to exceed ten (10) business days after the incident.
(IV) Each ALC having reasonable cause to
believe that a member is suffering from abuse, neglect, exploitation, or
misappropriation of member property must make a report to APS as soon as the
person is aware of the situation per 43A O.S. § 10-104.A. Reports are also
made to OSDH, as appropriate, per ALC licensure rules.
(V) The preliminary incident report must at
minimum, include who, what, when, where, and the measures taken to protect the
member and resident(s) during the investigation. The follow-up report must, at
minimum, include preliminary information, the extent of the injury or damage,
if any, and preliminary investigation findings. The final report, at minimum,
includes preliminary and follow-up information, a summary of investigative
actions representing a thorough investigation, investigative findings and
conclusions, and corrective measures to prevent future occurrences. When it is
necessary to omit items, the final report must include why such items were
omitted and when they will be provided.
(ix) Provision of, or arrangement for,
necessary health services. The ALC must:
(I)
Arrange or coordinate transportation for members to and from medical
appointments; and
(II) Provide or
coordinate with the member and the member's ADvantage case manager for delivery
of necessary health services. The ADvantage case manager is responsible for
monitoring that all health-related services required by the member as
identified through assessment and documented on the person-centered service
plan, are provided in an appropriate and timely manner. The member has the
freedom to choose any available provider qualified by licensure or
certification to provide necessary health services in the
ALC.
(E) ALCs
are billed per diem of service for days covered by the ADvantage member's
person-centered service plan and during which the ALS provider is responsible
for providing ALS for the member. The per diem rate for ADvantage ALS for a
member is one (1) of three (3) per diem rate levels based on a member's need
for type of, intensity of, and frequency of service to address member ADLs,
instrumental activities of daily living (IADLs), and health care needs. The
rate level is based on the Uniform Comprehensive Assessment Tool (UCAT)
assessment by the member's ADvantage case manager employed by a case management
agency independent of the ALS provider. The determination of the appropriate
per diem rate is made by the AA clinical review staff.
(F) The ALC must notify AA ninety (90)
calendar days before terminating or not renewing the ALC's ADvantage contract.
(i) The ALC must give notice in writing to
the member, the member's representative(s), the AA, and the member's ADvantage
case manager ninety (90) calendar days before:
(I) Voluntary cessation of the ALC's
ADvantage contract; or
(II) Closure
of all or part of the ALC.
(ii) The notice of closure must include:
(I) The proposed ADvantage contract
termination date;
(II) The
termination reason;
(III) An offer
to assist the member secure an alternative placement; and
(IV) Available housing
alternatives.
(iii) The
facility must comply with all applicable laws and regulations until the closing
date, including those related to resident transfer or discharge.
(iv) Following the last move to the last
ADvantage member, the ALC must provide in writing to the AA:
(I) The effective date of closure based on
the discharge date of the last resident;
(II) A list of members transferred or
discharged and where they are relocated; and
(III) The plan for storage of resident
records per OAC
310:663-19-3(g),
relating to preservation of resident records and the name, address, and phone
numbers of the person responsible for the
records.
(19) Remote Support (RS) services.
(A)
Purpose and
scope. RS services are intended to promote a member's independence and
self-direction. RS services are provided in the member's home to reduce
reliance on in person support while ensuring the member's health and safety. RS
services are included in the member's person-centered service plan and
coordination of these services are made through the case manager.
(i) RS services are:
(I) Based on the member's needs as documented
and supported by the member's person-centered service plan and person-centered
assessments;
(II) Only authorized
when submitted on the member's person-centered service plan with the consent of
the member, involved household members, and guardian, as applicable;
(III) The least restrictive option and the
member's preferred method to meet an assessed need; and
(IV) Provided when the member and the
member's Interdisciplinary Team (IDT) agree to the provision of RS services.
(ii) RS services are not
a system of surveillance or for provider convenience.
(B)
Service description. RS
services monitor a member by allowing for live, two-way communication between
the member and monitoring staff using one (1) or more of the following systems:
(i) Live video feed;
(ii) Live audio feed;
(iii) Motion-sensor monitoring;
(iv) Radio frequency
identification;
(v) Web-based
monitoring; or
(vi) Global
positioning system (GPS) monitoring devices.
(C)
General provider
requirements. RS service providers must have a valid OHCA SoonerCare
(Medicaid) provider agreement to provide provider-based RS services to
ADvantage HCBS waiver members and be certified by the AA. Requests for
applications to provide RS services are made to AA.
(D)
Risk assessment. Teams will
complete a risk assessment to ensure remote supports can help meet the member's
needs in a way that protects the right to privacy, dignity, respect, and
freedom from coercion. The risk assessment is reviewed, and any issues are
addressed prior to the implementation of remote supports general provider
requirements.
(i) Remote support providers
ensure the member's health and safety by contacting a member's informal support
or activating the member's back-up plan when a health or safety issue becomes
evident during monitoring.
(ii) The
risk assessment and service plan require the team to develop a specific back-up
plan to address health, safety and behavioral needs while remote supports are
utilized so appropriate assistance can be provided. The RS back-up plan
includes how assistance is provided to the member when equipment or technology
fails.
(E)
RS
guidelines. Devices or monitors are placed at locations based on the
member's individual needs as documented on the member's person-centered service
plan and approved by the member and involved family members and guardian, as
applicable.
(i) The use of camera or video
equipment in the member's bedroom, bathroom, or other private area is
prohibited.
(ii) When RS involves
the use of audio or video equipment that permits RS staff to view activities or
listen to conversations in the residence, the member who receives the service
and each person who lives with the member is fully informed of what RS entails.
The member's case manager documents consent in the member's person-centered
service plan.
(iii) Waiver members
have the ability to turn off the remote monitoring device or equipment if they
choose to do so. The RS provider educates the member regarding how to turn RS
devices off and on at the start of services and as desired
thereafter.
(F)
Emergency response staff.
(i)
Emergency response staff are employed by a certified ADvantage Provider with a
valid OHCA SoonerCare (Medicaid) contract to provide HCBS to OKDHS HCBS waiver
members.
(ii) Informal emergency
response persons are unpaid family members or other interested parties who
agree to become, and are approved as, an emergency response person by the
member and the member's IDT.
(G)
Service limitations. RS
services are limited to twenty-four (24) hours per day. RS services are not
provided simultaneously with any other in-home direct care services. However,
services may be provided through a combination of remote and in-home services
dependent on the member's needs.
(H)
RS service discontinuation.
The member and the member's IDT determine when it is appropriate to discontinue
RS services. When RS services are terminated, the RS provider coordinates
service termination with the member's case manager to ensure a safe
transition.
(20) Assistive Technology (AT) services.
(A) AT services include devices, controls,
and appliances, specified in the member's person-centered service plan, which
enable members to increase their abilities to perform activities of daily
living or to perceive, control, or communicate with the environment in which
they live.
(B) Devices may include
communication technology, such as smart phones and tablets, that allow members
to communicate with their providers using video chat to ensure ongoing
maintenance of health and welfare.
(C) Only devices that are not covered under
the SoonerCare (Medicaid) or Specialized Medical Equipment services are
included in this service definition.
(D) Service codes and rates vary based on the
nature of the AT device;
(E) AT
services may include:
(i) Assessment for the
need of AT or auxiliary aids;
(ii)
Training the member or provider regarding use and maintenance of equipment or
auxiliary aids; and
(iii) Repair of
adaptive devices; and
(iv)
Equipment provided may include:
(I) Video
communication technology that allows members to communicate with providers
through video communication. Video communication allows providers to assess and
evaluate their members' health and welfare or other needs by enabling
visualization of members and their environments. Examples include smart phones,
tablets, audiovisual or virtual assistant technology, or sensors; and
(II) The cost of internet services
may be augmented through the Emergency Broadband Benefit which is available to
waiver members.
Added at 12 Ok Reg 751, eff 1-5-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3131, eff 7-27-95 ; Amended at 14 Ok Reg 2827, eff 5-14-97 (emergency); Amended at 14 Ok Reg 3529, eff 7-23-97 (emergency); Amended at 15 Ok Reg 1528, eff 5-11-98 ; Amended at 16 Ok Reg 3627, eff 9-7-99 (emergency); Amended at 17 Ok Reg 1204, eff 5-11-00 ; Amended at 18 Ok Reg 265, eff 11-21-00 (emergency); Amended at 18 Ok Reg 501, eff 1-1-01 (emergency); Amended at 18 Ok Reg 1130, eff 5-11-01 ; Amended at 18 Ok Reg 2962, eff 5-17-01 (emergency); Amended at 19 Ok Reg 1067, eff 5-13-02 ; Amended at 19 Ok Reg 2134, eff 6-27-02 ; Amended at 20 Ok Reg 2892, eff 7-1-03 (emergency); Amended at 21 Ok Reg 2210, eff 6-25-04 ; Amended at 22 Ok Reg 2731, eff 5-4-05 (emergency); Amended at 23 Ok Reg 160, eff 7-1-05 (emergency) ; Amended at 23 Ok Reg 1366, eff 5-25-06 ; Amended at 24 Ok Reg 83, eff 8-2-06 (emergency); Amended at 24 Ok Reg 932, eff 5-11-07 ; Amended at 25 Ok Reg 660, eff 2-1-08 through 7-14-08 (emergency) 1 ; Amended at 25 Ok Reg 2685, eff 7-25-08 ; Amended at 26 Ok Reg 994, eff 5-1-09 (emergency); Amended at 27 Ok Reg 950, eff 5-13-10 ; Amended at 28 Ok Reg 1499, eff 6-25-11 ; Amended at 29 Ok Reg 192, eff 11-22-11 (emergency); Amended at 29 Ok Reg 1113, eff 6-25-12 ; Amended at 30 Ok Reg 1179, eff 7-1-13
1 This emergency action expired on 7-14-08 before being superseded by a permanent action. Upon expiration of an emergency amendatory action, the last effective permanent text is reinstated. Therefore, on 7-15-08 (after the 7-14-08 expiration of the emergency action), the text of 317:30-5-763 reverted back to the permanent text that became effective 5-11-07, as was last published in the 2007 OAC Supplement, and remained as such until amended again by permanent action on 7-25-08.
Disclaimer: These regulations may not be the most recent version. Oklahoma may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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