Personal Care (PC) is a medically related service to be authorized in conjunction with PDN. PC is designed to meet the maintenance needs of a participant with a chronic, stable condition delivered in the participant’s home. The possible range of services that may be authorized include basic PC Aide (PCA), Advanced Personal Care (APC) Aide, Waiver Attendant Care (WAC), and Authorized Registered Nurse (ARN) Visits . The ARN is used to train and evaluate the APC Aide. The authorized services are certified by a physician as the medically oriented tasks that are necessary to meet a participant’s physical needs. PC Aide services are intended to meet personal, physical requirements, as opposed to general housekeeping requirements, that enable the participant to remain in his/her home and maintain a functional capacity by fulfilling needs that cannot be met by other resources. Definitions to determine the appropriate level of services are as follows:

• PC Aide services must include the performance of direct hands-on assistance and cannot consist solely of oversight or supervision. PC Aide services are authorized when the participant requires assistance in one or more of the following categories that exceeds typical level of care for an individual of that age: dressing, grooming, bed mobility, toileting, bathing, eating, ambulating, transferring, and/or housekeeping. (NOTE:  MFAW PC Aides are not allowed to perform any skilled nursing tasks. These may include, but are not limited to, medication administration, g-tube feedings, suctioning, and any other doctor ordered treatments.) PC Aide services occur only in the home or residence of the participant.
• APC services are authorized to provide assistance with activities of daily living when such assistance requires devices and procedures related to altered body functions. Examples include: routine personal care for persons with ostomies and/or external, indwelling, and suprapubic catheters; use of lift, or other device for transfers; provide passive range of motion; apply non-sterile dressings to superficial skin breaks or abrasions; apply medicated lotions or ointments, and dry, non-sterile dressing to unbroken skin; administer prescribed bowel program; and/or manually assist with oral medications.
• ARN home visits is required when APC Aide services are authorized for the participant. The ARN visit is used to train and evaluate the APC Aide. Only one visit per month may be authorized. If the participant is receiving APC Aide services and PDN through the same provider agency, the PDN may provide this service. If there are no PDN services authorized through the same agency as APC Aide services then one monthly ARN visit is authorized.   
• WAC is defined as PCA services authorized through the MFAW Program that exceed 60% of the nursing home cost cap for state plan services. WAC services may be utilized for care inside and   outside of the home in the performance of normal life activities by waiver participants when medically necessary. The scope and nature of these services do not differ from State plan PC Aide services with the exception that WAC can be provided outside the home. 
  • When authorizing PC Aide with no APC or ARN, calculations will based on using 60% of the cost cap. If there is ARN and/or APC authorized in conjunction with PC Aide services, use 100% of the cost cap for those services. The remainder is calculated as WAC. Calculate in this order: ARN, APCA, PC Aide, and then WAC.  If there is WAC outside the home, it does not get counted toward the cost cap. It is important to utilize the appropriate tab of the calculation spreadsheet.

The parent/responsible party is the primary caregiver and the PC Aide is not to take the place of the parent/responsible party. It is not permissible for the parent(s)/responsible party(ies) to be away from the home with the expectation that the PC Aide provider agency shall accept total responsibility for the participant. The parent(s)/responsible party(ies) must designate an individual to provide direct care and for medical care decisions in the extended absence of the parent(s)/responsible party(ies). This designated individual shall not be an employee of the provider agency nor a SHCN employee.

PC Aide Assessment Tools

The Level of Care Determination Summary, Client Assessment Form, and the SCA will be completed by the SC to assist in determining medical necessity and the appropriate level of service.  In addition to these standard tools, the SC may review other sources of information to obtain sufficient understanding of the participant’s care, specific medical needs, and interventions. This may include:

• Physician's orders, plans of care, and/or medical reports,
• Provider progress notes and reports,
• A previous SHCN record,
• Documentation of verbal reports from the hospital discharge planners, service provider, Department of Mental Health Case Managers, and/or Family Support Division Case Workers, and
• Parent(s) and/or responsible party(ies) strengths and challenges that may affect the ability to provide care.

The SC will evaluate the family's ability to provide the participant's care by gathering other information such as:

• The family structure,
• Number of caregivers available,
• Routine absences of caregiver(s),
• Number, age, and health status of other household members,
• Mental and physical health of caregiver(s),
• Requirement of teaching the caregiver(s), and/or
• Willingness of the caregiver(s) to participate in the participant’s care.

PCA Assessment Process

Assessment is a continuous activity that begins when the referral/application is received and continues throughout the time the participant receives services. The SC must complete the SCA and all required forms (including, but not limited to, the Level of Care and Client Assessment) during a face-to-face home visit with the participant, parent(s), and/or responsible party(ies) within 10 business days of the receipt of the referral. The SCA must be completed initially, annually, and when warranted due to changing participant circumstances.

Information obtained during the SCA visit will be used in the development of the service plan. During the home visit, the SC will:

• Conduct an interview (using the SCA) with the participant, parent(s), and/or responsible party(ies) to obtain assessment information,
• Identify services that the participant is currently receiving,
• Explain the applicable MO HealthNet services that may be authorized through the MFAW Program,
• Complete all forms related to the type of service the participant requires,
• Have participant, parent(s), and/or responsible party(ies)sign any form requiring signatures,
• Determine if additional external supportive services are needed,
• Provide information about other resources that may be helpful to the participant, parent(s), and/or responsible party(ies), including contact names, addresses, and telephone numbers, and
• Assist family in locating a provider agency
  • Provide in-home service agency list with location and telephone numbers.

When the SCA and the home visit have been completed, the SC will:

• Enter the SCA information into the SHCN Information System
• Document the home visit using the appropriate template and contact type in the SHCN Information System

Based on the data gathered above and in discussion with the participant, parent(s), and/or responsible party(ies), the SC determines the frequency, amount, and duration of services needed to meet the medical needs of the participant. There is not a minimum number hours that may be authorized.

Required forms for Personal Care Services

• SCA (Annually)
• Level of Care (Every 6 months)
• Client Assessment Form (Every 6 months)
• DHSS Notice of Privacy and Privacy Policies Acknowledgement (Annually)
• Authorization for Disclosure of Consumer Medical/Health Information (As Necessary)
• Rights and Responsibilities (Annually)
• Prior Authorization Form (PA) (Every 6 months)
• Confirmation of Verbal Authorization (Initially, annually and with changes to authorization)
• Expectations For In-Home Services (Signed Annually and copies given quarterly)
• Services/Participant Preferences Form (Initially, annually, and with changes to authorization)

Program Manager Authorization Approval

A PM change request is completed for a variety of reasons which include, but are not limited to:

• Any change in authorized PCA, APC, WAC and/or ARN services
• Any PCA PRN authorizations outside of multiple agencies in the home with shared PRN
• The authorization for services exceeds 112 hours/week, including PRN hours
  • PM Change Requests are not required for the addition of PRN hours that are authorized solely to be shared between multiple providers for shift coverage purposes and worded as such that the overall authorization should not be exceeded between the providers
  • If a participant’s authorization exceeds 112 hours/week, a PM Change Request must be approved annually at the time of the participant’s SCA

The SC completes all the sections of the PM Change Request form and submits it to the RC. The RC assigns it to another SC for peer review, as needed. The PM Change Request is then returned to the RC for review and recommendations. The RC will send the PM change request to the MFAW PM and copy the Associate Bureau Chief for review and approval.  When applicable, the original PM Change Request form will be used to complete required updates for re-approval. Re-approval to continue the current authorization should only be submitted annually at the time of the SCA visit. The information on the new addendum will be designated by documenting in a different color corresponding to the date of the new request. Every addendum submitted must address each section of the document.

Provider Selection

The SC will provide the participant, parent(s), and/or responsible party(ies)with a regional provider list that includes current agency contact information.

• The participant, parent(s), and/or responsible party(ies)will select a provider agency within 30 days of receipt of the provider list.
• If the participant, parent(s), and/or responsible party(ies)has not chosen a provider agency in 30 days, the SC will contact the family to offer assistance with provider selection. If assistance is requested, the SC will inquire with provider agencies regarding staffing availability. Results will be communicated to the participant, parent(s), and/or responsible party(ies)for provider selection.
• If the participant, parent(s), and/or responsible party(ies)has not selected a provider agency in 90 days of receipt of the provider list, SHCN will close the case and send a closure letter.

Service Authorization

Once a provider agency is chosen by the participant, parent(s), and/or responsible party(ies), the SC contacts the provider agency to discuss the service authorization. A MFAW Confirmation of Verbal Service Authorization (VC) is sent to the provider agency to be signed and returned to SHCN. This form is filed in the participant’s chart.

Plan of Care

The provider agency is responsible for obtaining a Plan of Care and the Physician’s Certification of Need with the physician’s signature. The provider agency may choose to do a 485 in lieu of the Plan of Care and Physician Certification of Need. The Plan of Care specifies the type, frequency (number of 15 minute units per day or per week), and duration (how many weeks or months) of services to be provided as well as the specific PC Aide and/or APC Aide tasks to be completed. The provider agency is responsible for submitting the Plan of Care and a signed Physician’s Certification of Need to SHCN.  The Plan of Care and Physician Certification of Need are to be reviewed and re-established by the physician at least every six months and include the following elements:

• Changes to frequency or type of services authorized during a certification period must be authorized by the physician by way of verbal or written order,
• All pertinent diagnoses must be included on the Physician’s Certification of Need, and
• Frequency and duration of services including the type of professional to provide the authorized services.

Upon receipt of this documentation from the agency, the SC and the Facilitator will review for accuracy and appropriate content. The Facilitator will complete the Prior Authorization Request form and enter the Service Plan section in the SHCN Information System. Upon completion, the SC will sign and date the PA indicating approval. PC Aide/APC Aide/ARN services may not be authorized for longer than a six month period. 

Required Contacts and Home Visits

Initial Home Visit

• The SC completes a SCA during the initial home visit with the participant, parent(s), and/or responsible party(ies) within 10 business days of the date of the referral.  The RC or the MFAW PM may grant exceptions to this requirement.

Annual and Routine Home Visits

• The SC completes a SCA annually during a home visit with the participant and participant, parent(s), and/or responsible party(ies). Home visits are required every six months and the participant must be seen. It is expected that the participant, parent(s), and/or responsible party(ies) participate in all home visits except in extenuating circumstances with the RC approval. The SC will document home visits in the SHCN Information System using the appropriate home visit template.

Place of Service

PC Aide/APC Aide services are only to be provided in the home or residence of the participant, parent(s)/responsible party(ies) or other caregiver. WAC services may be utilized for care inside and outside the home in the performance of normal life activities by waiver participants when medically necessary. The scope and nature of these services do no differ from state plan PC Aide services with the exception that WAC can be provided outside the home. The PC Aide/APC Aide/WAC may not drive the participant or provide care for the participant in the aide’s home.

Two or more participants in the same residence

When two or more participants residing in the same residence require PC Aide/APC Aide services and their personal care needs can be met by one staff person during the same timeframe, the total units authorized for each participant shall be based on each individual’s needs and may not exceed the actual amount of time (in 15 minute units) the PCA is in the home. The SC will authorize only the medically necessary units of service required.

When PC Aide/APC Aide services are approved for two participants at the same time, the SC will complete a new VC for each participant and send to the provider agency.

Example:

• Four hours/day of PC Aide/APC Aide to be shared with other sibling in home (do not specifically name other sibling).

In instances when there is a large variance in the medically necessary care of the participants, the SC must consult with the RC and MFAW PM to discuss the appropriate services to authorize for each participant.

Authorization of PRN Hours

Inclusion of PRN hours when authorizing PCA/APC services is uncommon and should only be considered in extenuating circumstances or when multiple providers are in the home.

• PCA PRN solely for multiple agencies to cover missed shifts requires RC approval through VC review
  • SC will submit the VC with the requested PCA authorization to the RC, including an outline that the PRN hours are authorized to allow flexibility when there is coverage by multiple agencies
  • In this instance, a portion of the authorized hours are designated as PRN that can be used by multiple agencies serving the same participant and the total authorized PCA hours should not be exceeded
• Any PCA PRN authorizations outside of multiple agencies in the home with shared PRN requires approval through a PM Change Request

Discontinuation of PCA Services

Participant records are closed by the SC for various reasons. In all instances, good faith efforts must be made and documented in the SHCN Information System to show effective service coordination, and when appropriate, successful transition from MFAW services. Reasons for closure may include:

• The applicant/participant demonstrates an unwillingness to cooperate with MFAW requirements,
• Participant does not meet eligibility criteria,
• Request of the participant, parent(s), and/or responsible party(ies),
• Unable to locate after good faith efforts, or
• The participant has become institutionalized or a Ward of the Court with guardianship assigned.

Once the determination has been made to close services, the SC will complete and send a closure letter indicating the reason for closure along with the closure date, allowing 10 calendar days for response prior to closure. This action will also be documented in the SHCN Information System. Exceptions to the 10 calendar day closure rule include the following:

• Moved out of state – date of move if known; otherwise use the date that staff

became aware of move.

• Deceased - date of death if known; otherwise use the date staff became aware of the death.

Discontinuation of the delivery of PC Aide/APC Aide Services by Provider Agencies

Providers must give notification to the participant, parent(s), and/or responsible party(ies) and SHCN prior to the discontinuation of services. The PC Aide/APC Aide service provider notifies the participant, parent(s), and/or responsible party(ies) in writing of the decision to discharge a participant and provides a minimum of 21 day notice prior to the discontinuation of services for reasons that include, but are not limited to, the following:

• The participant, parent(s), and/or responsible party(ies) are non-compliant to the agreed upon Plan of Care,
• The provider is no longer able to meet the service needs of the participant, and/or
• The participant, parent(s), and/or responsible party(ies) requests a change.

The PC Aide/APC Aide provider agency shall advise SHCN within 72 hours of the

participant, parent(s), and/or responsible party(ies) notification of planned discontinuation of PC Aide/APC Aide services. The SC shall assist the participant, parent(s), and/or responsible party(ies) in making appropriate arrangements to locate and transfer care (if possible and necessary) to a new provider agency. The provider agency shall notify SHCN within 72 hours of closure of a case due to the following circumstances:

• Death of the participant
• Participant’s admission to a health care facility
• Participant is no longer in need of care

Exceptions for Special Circumstances

• Acute or Intense Needs: When the participant, parent(s), and/or responsible party(ies) requests a notable increase in personal care PC Aide or combined PC Aide with APC Aide due to an acute or intense need, the SC confers with the RC who may include the MFAW PM if necessary.

In addition, for any combination of service authorization (PC Aide, APC Aide, PDN) exceeding 16 hours/day or 112 hours/week, the SC must complete a PM Change Request form to submit to the RC to facilitate a peer review. Once the peer review is completed, the RC makes their recommendation and then forwards the request to the PM for review and approval/denial. These requests must be completed each time a new authorization period is to begin.

Exclusions

• The PC Aide/APC Aide employed by the agency who actually delivers the personal care service must not be a family member. A family member is defined as a parent; sibling; child by blood, adoption, or marriage; spouse; grandparent; or grandchild.
• PC Aide/APC Aide services are not authorized for a participant receiving inpatient hospital services or residing in a skilled nursing facility, intermediate care facility, or any other institutional setting or health care facility.