Home and Community Based Services Manual


3.20 RCF/ALF Personal Care – State Plan (Agency Model)

Introduction

Personal Care (PC) services are maintenance services provided to residents of Residential Care Facilities (RCF) or Assisted Living Facilities (ALF) to assist with activities of daily living (ADL). Services are authorized to eligible residents when the resident's needs exceed the facility's minimum obligations as established in the licensure requirements.

RCFs or ALFs are responsible, at a minimum, for the basic human needs of its residents. The facilities are also responsible for assuring the resident's PC needs are met through the resident's resources or other available resources. The facilities are responsible for 24-hour protective oversight of residents and room and board. The reimbursement the facility receives from the resident (Supplemental Security Income (SSI), Social Security Administration (SSA), etc.) and a supplemental cash grant from the Department of Social Services (DSS) is intended to cover safe shelter needs (including housekeeping, basic linens, and the maintenance thereof) and nutritional needs (food and food preparation).

Purpose

RCF/ALF Personal Care services are designed to support residents' additional needs in this setting and are funded through Medicaid State Plan. Basic Personal Care, Advanced Personal Care and Authorized Nurse Visits are all allowable service types offered to residents with an identified need that goes above and beyond the facility's basic requirements.

Eligibility

All PC participants must meet the following eligibility criteria to receive services in an RCF/ALF:

  • At least 18 years of age
  • In active Medicaid status:
    • Participants eligible for Medicaid on a spenddown basis may be authorized to receive services during periods they meet their spenddown liability.
    • A participant is responsible for the cost of services received during periods of time when they have not met their spenddown liability.
    • Participants who receive Medicaid due to eligibility for Blind Pension (BP) may be authorized for services in the RCF or ALF.
      • Participants in a ‘Transfer of Property penalty’ may be authorized for services in the RCF or ALF.
    • Have an appropriate Medicaid Eligibility (ME) Code.
  • Meet nursing facility level of care (LOC)

Referrals

Referrals for PC services shall be made to the Department of Health and Senior Services (DHSS), Division of Senior and Disability Services (DSDS). DSDS shall screen and process the referral as appropriate, utilizing the same timeframes as all other HCBS.

HCBS participants requesting PC services may make a referral by contacting the HCBS Customer Service Center. Providers should initiate referrals by utilizing the Online HCBS Referral Form. In instances when referrals cannot be submitted online, referrals can be submitted by completing the Home and Community Based Services Referral Form. In addition to the referral forms, referrals may include a Physician’s Prescription for Personal Care.

Assessment

When arriving at an RCF/ALF and completing a (re)assessment, DSDS staff or its designee shall:

  • Announce themselves to facility staff and indicate the intent of the visit before meeting with the current or potential participant
  • Document the room condition where the current or potential participant resides in case notes
  • DSDS or its designee must review the participant’s facility chart to verify information that will assist in determining the (LOC) and assistance needed. Items to verify include but are not limited to:
    • Diagnosis and frequency of mental health physician visits
    • Physician-ordered treatments, medications, or special diets the participant receives
  • Make other collateral contacts, including, but not limited to, RCF or ALF staff (Administrator/manager, licensed nurse, PC aide who provides daily services), family, friends, legal representatives, or physicians to obtain information to complete the assessment process
  • Make decisions regarding the authorization of PC services in consultation and agreement with the participant, the participant’s legal representative (if applicable), and the participant’s physician
  • Ensure the services authorized shall reinforce and enhance the participant's current formal and informal support system
    • Reimbursement for PC services cannot duplicate what is covered in other reimbursements to the facility (e.g., routine linen changes and meal preparation).

Authorization

RCF/ALF PC services are also governed by the average statewide monthly cost for care in a nursing facility. PC units shall be authorized as outlined below:

  • PC services shall not exceed 60% of the cost maximum
  • The 60% cost maximum can be exceeded by the cost of APC and RN visits, but only up to the full monthly cost of 100%
  • All combined PC services shall not exceed 100% of the average statewide monthly cost for care in a nursing facility

NOTE: When the care plan includes authorization for RN services, the cost of one RN visit shall be excluded from the calculation of a care plan’s cost.

Tasks

Residents who meet the necessary Medicaid eligibility requirements may be authorized for any of the following combinations of services provided.

Basic Personal Care

Basic Personal Care (PC) services in RCF/ALF shall be authorized in 15-minute units and are generally medically oriented tasks designed to meet the physical and maintenance needs of participants with chronic, stable conditions. PC may include the following tasks:

  • Bathing
    • Direct assistance with bathing and shampooing hair that requires active participation by the aide. (e.g. hands-on washing assistance, assistance in or out of the bath, gathering supplies/clean clothing, etc.) (Suggested time 15-45 minutes per bath)
  • Dietary
    • Direct assistance with meal preparation, feeding and clean up. Dietary shall be authorized when the participant has a physician-ordered specialized diet. Dietary may also be authorized if the participant needs assistance with feeding, cutting up food, carrying a tray to the table, opening containers, etc. Authorization of service units must be based on the participant’s specific needs. (Suggested time 15- minutes per meal)
    • DSDS or its designee shall review any physician-ordered diet before authorizing units for dietary needs. No units shall be authorized for meal preparation and clean-up unless facility staff exceeds licensure requirements.
  • Dressing/Grooming
    • Direct assistance with dressing and undressing, combing hair, nail care, oral hygiene, shaving, and assisting with prosthetics. (Suggested time 15 minutes per dressing instance)
  • Medically Related Household Tasks
    • Assistance with required cleaning that goes above and beyond the minimum housekeeping requirements of the facility. Time may be authorized if the participant has a medically related need that requires the facility staff to clean a resident’s living area more often than usual (e.g. profuse bodily secretions, excess bodily fluids from incontinence, destructive tendencies, hoarding, etc.). DSDS or its designee can authorize services to clean the resident’s living area and launder the resident’s clothes and linens. (Suggested time 15-minutes per instance)
  • Mobility and Transfer
    • Direct assistance with mobility, transfer, and ambulation when the participant can at least partially bear their weight. (Suggested time 5-10 minutes per instance)
  • Self-Administration of Medications
    • Direct assistance with medications and applying nonprescription topical ointments or lotions (e.g. the time spent handling the medication container, including inhalers, medicines for nebulizers, ointments/lotions, steadying the participant’s hand/arm to get oral medication and inhalants to mouth, and water to the participant. (Suggested time 1 unit/day for self-administration of medications taken up to 3 times daily; 2 units/day for medications taken 4 or more times daily)
      • Medication administration is not a covered task within the PC program. The self-administration of medication task does not include the time required by facility staff to administer the medication. Administration of medication is defined in 19 CSR 30-86.042(51) as delivered to a resident their prescription medication either in the original pharmacy container or for internal medication, removing an individual dose from the pharmacy container and placing it in a small container or liquid medium for the resident to remove from the container and self-administer.
  • Toileting
    • Direct assistance with toileting tasks. This may include assistance using or transferring to/from the toilet, commode, bedpan, urinal, cleansing after use and assistance with incontinence episode(s) (The suggested time is 5 minutes multiplied by times per day based upon the suggested frequency needed).
      • Encouragement (prompting and cueing) and instruction of participants in self-care may be a component of the services; however, encouragement and instruction do not constitute a task in and of themselves.

Advanced Personal Care

Advanced Personal Care (APC) services shall be authorized in 15-minute units and are medically oriented tasks designed to meet the physical and maintenance needs of participants with a chronic, stable condition when such assistance requires devices and procedures related to altered body functions. APC may include the following tasks:

  • Aseptic Dressings
    • Application of dressings to superficial skin breaks or abrasions as directed by a licensed nurse. (Suggested time 15 minutes per ordered instance)
    • Application of medicated (prescription) lotions and ointments to unbroken skin, including stage 1 decubitus. (Suggested time 15 minutes per ordered instance)
  • Bowel Program
    • Administration of prescribed bowel programs, including suppositories and sphincter stimulation per protocol and prepackaged enemas for participants without contraindicating rectal or intestinal conditions. (Suggested time 15 minutes per ordered instance)
  • Catheter Hygiene
    • Changing of bags, soap and water hygiene around the site of external, indwelling, and suprapubic catheters. (Suggested time 15- minutes per instance)
    • Removal of external catheters, skin inspection, and catheter reapplication. (Suggested time 15- minutes per instance)
  • Non-Injectable Medications
    • Manual assistance with non-injectable medications, as set up by a licensed nurse, may include opening a medicine lockbox, steadying the participant’s hand/arm for ear and eye drops, finger sticks for blood sugar monitoring and reading levels and when prompting is required to take medication. (Suggested time 15 minutes per ordered instance)
  • Ostomy Hygiene
    • Changing of bags, soap and water hygiene around a well healed ostomy site (including tracheostomies, gastrostomies, and colostomies). (Suggested time 15- minutes per instance)
  • Passive Range of Motion
    • Administration of movement of a joint through its full range of motion, delivered in accordance with the care plan. (Suggested time 15 minutes per ordered instance)

Authorized Nurse Visits

Authorized Nurse Visits (RN) are authorized by the visit. No minimum or maximum time is required to constitute a visit. RN services are maintenance or preventative services provided by a Registered Nurse (RN) or a Licensed Practical Nurse (LPN) under an RN's or physician's direction.

Authorized Nurse Visit tasks may include:

  • Evaluate APC Care Plan
    • All APC participants shall be authorized for an RN visit monthly to evaluate the adequacy of the authorized services to meet the participant’s needs and assess the APC aide’s ability to carry out the authorized services.
  • Other RN Care
    • Monitor skin condition(s)
    • Nail care: Monthly visits to provide nail care for diabetic participants or participants with other medically contraindicating conditions, including but not limited to participants:
      • Taking anticoagulant medication
      • Diagnosed with peripheral vascular disease
      • Diagnosed with a compromised immune system
    • Administration of injectable medications (other than insulin)
    • Venipunctures
    • Catheter changes
    • Enemas (only when not utilizing a prepackaged enema)
    • Central line dressing/flush/blood draws

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