Home and Community Based Services Manual

Introduction

The development of a person centered care plan (PCCP) is the result of a thorough review of the participant’s needs. PCCPs are individualized in accordance with the unmet needs of the participant and outline what services are necessary to keep the participant living independently in their home. HCBS authorized within the PCCP shall be mutually identified as necessary by the participant and the Department of Health and Senior Services (DHSS), Division of Senior and Disability Services (DSDS) or its designee. The PCCP process assesses the health and safety factors of the participant and outlines the participant’s personal goals in order to remain in their least restrictive environment.

Purpose

The PCCP translates identified participant specific needs into a plan for action. The identification of functioning problems, current resources (formal and informal), unmet needs, and related documentation shall serve as the foundation for developing the PCCP. The HCBS authorized under the PCCP shall strengthen and enhance the current support system of the participant.

The following basic principles shall be used as a guide for PCCP development:

• A comprehensive, thorough review of the participant’s current abilities shall determine the needs of the participant
• The participant and anyone asked by the participant, may be involved in the PCCP development process
• Planning shall involve both formal and informal supports
• The PCCP shall reflect cost awareness

Note: For a participant who has a legal representative (e.g., guardian, or someone with a Durable Power of Attorney (DPOA) in effect), it is required the legal guardian be notified and given the option to assist with the development of the PCCP. If a guardian has been identified, DSDS staff, or its designee shall obtain copies of the guardianship paperwork and attach them to the electronic case record.

Person Centered Care Plan Development

Process

A PCCP shall be developed with and agreed upon by the participant and/or legal guardian during the development process and authorization of HCBS.

Authorized HCBS shall not replace or duplicate existing formal or informal support systems without adequate documentation that such support will no longer be available to the participant.

The following shall be determined:

• If there are any support systems currently in place that will not be continued, and the reason why
• The tasks requiring the authorization of HCBS or referral to another entity

Authorizing certain HCBS when the participant lives with others who are able to perform those services or tasks is not appropriate, as explained below:

• Tasks such as cleaning shared areas, (areas used by other household members of the residence), shall not be authorized.
• Tasks that are a primary benefit to a household unit or when members of the participant’s household may reasonably be expected to share or do for one another shall not be authorized (unless such tasks are above and beyond typical activities household members may reasonably provide for one another).

Note: Assistance with meal preparation based on preference (e.g. eating at different times or prefer different foods) shall not be authorized for participants who live with others and have the availability of shared meals.

Thorough documentation shall support the reasons why other household members or current support systems cannot complete necessary tasks. Services authorized shall only be those required to meet the participant's needs.

As part of the PCCP development, the following shall be taken into consideration:

• The aide’s ability to perform multiple tasks within the same timeframe
• Size of the participant’s living area
• Assistance provided by others in the household
• Assistance provided by other formal and informal supports
• Access to transportation, including the availability of MO HealthNet Non-Emergency Medical Transportation (NEMT)
• Availability of laundry facilities
• Any other factors that may influence the type and amount of services required to meet the participant’s needs

In all instances, DSDS staff or its designee shall authorize HCBS necessary to meet the participant’s identified unmet needs within the appropriate services guidelines as described in the HCBS Policy, Chapter 3. All service authorizations must be supported by thorough documentation within the electronic case record and must be reasonable and necessary according to the participant's condition and functional capacity.

A referring entity can make suggestions as a collateral contact during the development of the PCCP. However, DSDS staff or its designee must primarily consult with the participant and/or legal guardian to determine unmet needs and arrange the services necessary.

Collateral Contacts

Additional information may be needed to assist in the PCCP development and coordinate care for the participant. Independent collateral contacts shall not compromise the rights and confidentiality of the participant. When considering collateral information during the design of the PCCP, sufficient documentation shall explain any discrepancies in the expressed wishes of the participant. Collateral contacts should be an individual(s) familiar with the needs of the participant.

Unless prevented by circumstances, a discussion shall be conducted with the participant and/or legal guardian during the PCCP process, indicating what information will be obtained and sources contacted. The appropriate privacy policies in HCBS Policy, Chapter 9, shall be reviewed with the participant and/or authorized representative.

Resources which may assist in PCCP development include:

• Medical sources: Information regarding the current medical condition, prior authorizations, history, and limitations may be obtained through the participant’s electronic case record, physicians, hospitals, clinics, and home health agencies.
• Relatives, neighbors, and friends: These individuals may be able to provide additional observations and information regarding the participant when identified as a part of the informal support system.
• Other Social Agencies: Information may be available through local community agencies providing support or services to the participant.
• Agencies: Services may be accessed through various state agencies and funding sources designed to care for participants with specific medical conditions. Participants in need of such services shall be referred, and care will be coordinated in an effort to maximize state and federal resources. Information shall be obtained to determine and coordinate services currently authorized by:
  • Department of Mental Health
  • Department of Social Services
  • Other Divisions within DHSS
  • Home Health
  • Hospice

DSDS staff or its designee shall complete all related PCCP activities including entry of the service authorizations for HCBS as soon as possible.

Backup Plan

As part of the PCCP maintenance process, DSDS staff shall determine if the backup plan is still appropriate. If necessary, DSDS staff shall work with the participant to ensure the backup plan is updated and current information is provided.

The backup plan shall be provided in the event of an emergency and when the HCBS provider is unable to deliver services due to temporary staffing shortages, natural or other disasters, and acts of terrorism. A backup plan may include more than one individual. The following shall be included for each individual listed as part of the plan:

• Name
• Relationship to the participant (e.g., family, friend, neighbor, etc.)
• Contact information (phone number)
• A brief summary of the assistance the individual will provide in the event HCBS are unable to be delivered.

Note: 911 should only be used in rare instances and as the last option for participants with no other alternatives or support system (i.e. family, neighbor, friend, etc.). If 911 is the only alternative for an emergency contact, case note documentation shall thoroughly explain there are absolutely no other options available.

COOP Priority

A COOP priority risk indicator will display on the participant screen of the participant’s electronic case record. This indicator can be updated at any time during the authorization period. These indicators are intended to assist the HCBS provider in prioritizing service delivery in instances such as temporary staffing shortages, natural or other disasters, and acts of terrorism.

Document the level of priority by evaluating circumstances (i.e., support system, confusion, and noncompliance) in the electronic case record. Risk indicator of one (1) shall be used when the lack of HCBS would pose a serious threat to the health, safety, and welfare of the participant. Discretion shall be used in assigning high priority. A fragile, unreliable or insufficient support system must be documented in the electronic case record, justifying high priority status.

Authorization

Specific services may have associated tasks. Suggested tasks that are mutually identified and agreed upon shall be selected. Suggested times and frequencies are provided for these tasks as a standard baseline. Task frequencies that are significantly different from the suggested time and frequency shall be documented within the participant’s electronic case record.

When developing a PCCP the following shall be taken into consideration:

• Personal Care (PC) shall be included in the overall cost of care for the participant as referenced in the HCBS Cost Maximums policy.
• PC services shall not exceed 60% of the cost maximum
  • The combination of agency model PC and CDS shall not exceed 60% of the cost maximum.
  • The cost of authorized nurse visits is not included in the 60% monthly maximum cost for basic personal care.
• 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%.

Note: When the PCCP includes an authorization for RN services, the cost of one RN visit shall be excluded from the calculation of a PCCP’s cost. These costs will not display in the total calculated cost maximum in the participant’s electronic case record.

• When the combination of PC, other State Plan services, and an HCBS Waiver (e.g., Aged and Disabled Waiver (ADW) or Independent Living Waiver (ILW)) exceeds 100% of the monthly cost maximum, approval is required from the Bureau of Federal Programs (BFP).
  • The appropriate supervisor for DSDS staff shall review all PCCP requests over the 100% cost cap to ensure the participant’s unmet needs require the amount of service requested.
  • If documentation supports the request, the case shall be forwarded to BFP for consideration and approval prior to authorization over 100% of the cost cap.
    • Pending the approval from BFP to exceed the cost maximum, PC services in combination with other State Plan or ADW or ILW services can be authorized up to 100% of the cost maximum.
• When a PCCP includes Adult Day Care authorized through the ADW or the Adult Day Care Waiver (ADCW), the total cost of care cannot exceed 100% of the cost maximum.

Note: Pursuant to federal guidelines, a participant can only be enrolled in one HCBS waiver at a time, regardless of which department administers the waiver program.

Provider Selection

Choosing an HCBS provider is the right and responsibility of the participant and/or legal guardian. DSDS staff or its designee shall explain that selecting an HCBS provider is part of the PCCP process. Upon request, a list of all qualified HCBS providers in their geographic location shall be provided to assist in the selection process. Participants shall contact potential HCBS providers to discuss specific company practices, such as policies, hours, etc.

DSDS staff or its designee shall coordinate all service authorizations with the selected HCBS provider to ensure they are able to accept the new care plan. This may involve multiple contacts to ensure the provider’s capacity to deliver HCBS. The HCBS provider may review the participant’s electronic case record prior to accepting the participant. All contacts made with or on behalf of the participant shall be thoroughly documented in the electronic case record.

Active HCBS participants will have ten (10) business days to select another HCBS provider whenever a twenty-one (21) day notice has been issued from their current provider or Missouri Medicaid Audit and Compliance (MMAC) notifies DSDS that a provider’s contract will be closing. In areas where it is known that HCBS providers are experiencing staff shortages, the participant and/or legal guardian shall be asked to note a backup HCBS provider in the event the first choice is not able to accept a new case.

If the participant and/or legal guardian does not select a new HCBS provider that can accept the PCCP the following may occur:

• DSDS staff shall initiate an adverse action, referring to the Adverse Action policy
• DSDS staff shall allow ten (10) calendar days from the date of the adverse action for the participant and/or legal guardian to choose an HCBS provider that is able to accept the PCCP
• If a new HCBS provider is not chosen within ten (10) calendar days, DSDS staff shall close the relevant service type(s) and/or case.

If the participant and/or legal guardian contacts DSDS staff within ninety (90) calendar days from the date of the adverse action with a new HCBS provider that can accept the PCCP:

• DSDS staff who initiated the adverse action will open the case and enter the selected HCBS provider if an assessment was completed ninety (90) calendar days prior to the date of the adverse action.

Note: DSDS staff should refer the participant to the Bureau of HCBS Intake and PCCP Customer Service Contact Center to initiate a new referral for services if the participant and/or legal guardian contacts DSDS after ninety (90) days of the adverse action.

After exhausting all qualified HCBS providers in the geographic location, if an HCBS provider is still not available, the participant shall be moved into State Designee Status. DSDS staff shall refer to the Adverse Action policy.

Person Centered Care Plan Completion

Upon completion of the selection of all requested services, DSDS staff, or its designee shall review and complete the PCCP with the participant. All information on the applicable Rights and Responsibilities form(s) shall be discussed with the participant and/or legal guardian.

HCBS providers shall be instructed to access the PCCP via the participant’s electronic case record and will receive an alert regarding a PCCP authorization. This will remain in the ‘My Agencies Participant's” queue. When a change has been made to the care plan, an alert will display in the provider's queue to accept or reject the care plan changes and start date.

All HCBS participants shall receive a copy of the PCCP detailing the authorization of their HCBS. HCBS providers shall provide a copy of the PCCP to the participant. DSDS staff shall send the PCCP upon participant request.

Note: Pursuant to Section 191.656, RSMo HCBS providers serving an individual with HIV or AIDS may only disclose the health status of the individual to employees providing direct health care services to the individual only after the provider has determined the employee has a reasonable need to know. Such disclosure should be done in strictest confidentiality and prohibit further disclosure.

Person Centered Care Plan Maintenance 

DSDS staff or its designee shall conduct all PCCP maintenance activities within the electronic case record. A participant’s PCCP shall be modified to address unmet needs resulting from changes in the participant’s health, supports, safety and abilities.

• Increasing or decreasing services/tasks
• Adding or deleting services/tasks
• Changing HCBS providers
• HCBS case closure

DSDS staff or its designee may receive a request for a PCCP change through several different sources, including, but not limited to:

• The participant and/or legal guardian
• The HCBS provider
• Formal or informal support
• A community resource (e.g., senior center, hospital, etc.)
• Participant’s physician
• MMAC

Administrative oversight of HCBS includes timely action and closing of cases with an expired PCCP. However, extenuating circumstances may preclude closing a case on a timely basis. These may include, but are not limited to:

• Participant is deceased and DSDS staff did not receive notification
• Participant has requested a hearing due to an adverse action
• Participant is waiting for a hearing decision
• DSDS staff is waiting for the return of physician or other collateral information.

When such circumstances delay the timely closing of cases with an expired PCCP, DSDS staff or its designee shall make the appropriate documentation in the participant’s electronic case record with follow-up as necessary until the closing action is completed.

As with any maintenance activity, the basic principles of the PCCP process shall be followed:

• The participant and/or legal guardian shall be consulted in all instances when a change to the PCCP has been requested. DSDS staff or its designee shall make additional contacts, as necessary, to verify status changes that warrant the requested modification to the PCCP.
• DSDS staff or its designee shall coordinate with the participant’s HCBS provider on all changes to the PCCP.
• If a new service type is added to the PCCP, a copy of the appropriate Rights and Responsibilities form shall be provided to the participant.
• When changes are made to a PCCP for a participant authorized for services through the Department of Mental Health (DMH), a copy of the new PCCP shall be forwarded to the Division of Developmental Disabilities (DD) support coordinator.
• All maintenance activities that adversely affect the participant’s PCCP shall be subject to the Adverse Action process.

Person Centered Care Plan Change Request

In instances of a PCCP change request:

• DSDS staff shall make one (1) attempt to contact the participant and/or legal guardian at each number listed on the request.
  • If a voicemail can be left, DSDS staff shall leave a detailed message, including the purpose of the call and the date on which the participant must return the call to proceed with the request. DSDS staff shall provide the participant and/or legal guardian ten (10) calendar days to respond.
  • If a voicemail cannot be left, DSDS staff shall send a Participant Contact Letter.
• All contacts shall be thoroughly documented in the participant’s electronic case record.

Note: The ten (10) calendar days shall begin the first calendar day after the Participant Contact Letter is mailed. If the 10th calendar day ends on a State Holiday or weekend, the next business day shall be considered the 10th day (e.g., if the 10th calendar day ends on Saturday the next business day is Monday).

Adverse actions are not required if the reductions or closing requests are agreed upon through a discussion between DSDS staff and the participant and/or legal guardian. In instances where a participant and/or legal guardian requested a reduction or closure of services, DSDS staff shall verify the identity of the participant and/or legal guardian and document in the electronic case record. Actions of this nature may be taken immediately.

PCCP changes resulting in a decrease only are to be authorized with an effective date on the first day of the month following the date of change. If an adverse action has been initiated, the change will take affect the first day of the next month following the expiration of the adverse action.

When a PCCP change includes an increase, even if a particular task(s) was decreased or removed, the effective date is based on participant need and provider availability. Therefore, effective dates for PCCP changes with both an increase and a decrease may occur anytime during the month.

All contacts shall be thoroughly documented in the participant’s electronic case record, referring to Case Notes Documentation.