Home and Community Based Services Manual


4.25 Provider Reassessment Process

Introduction

In order to continue to improve efficiency and operations in the reassessment and care planning process for Home and Community Based Services (HCBS), HCBS providers may enroll as Medicaid Type 27 providers to gather the information necessary for the Division of Senior and Disability Services (DSDS) to determine the continued eligibility for HCBS as authorized by DSDS. Enrollment in the HCBS provider reassessment program is voluntary. This policy outlines the reassessment process for HCBS providers approved to complete reassessments for DSDS. Enrolled HCBS providers shall ensure the qualified reassessors have completed the required DSDS sponsored training prior to completion of any reimbursable reassessment. HCBS provider assessors are expected to follow policy and procedures outlined in the DSDS sponsored training, HCBS policy, memorandums and any additional HCBS guidance. The Provider Reassessment Information page contains additional information.

Purpose

The purpose of the reassessment is to:

  • Establish continued eligibility for HCBS (i.e. Medicaid, Nursing Facility Level of Care (LOC) and continued unmet needs)
  • Ensure the adequacy of the Person Centered Care Plan (PCCP)
  • Assess new unmet needs that may require additional HCBS authorization
  • Complete all necessary documentation and required forms
  • Determine the participant’s satisfaction with the current HCBS provider

All participants authorized for HCBS shall have a reassessment completed within 365 days from the last LOC determination. HCBS providers enrolled to perform reassessments shall perform face-to-face visits to complete the reassessment with the participant, utilizing the InterRAI HC.

HCBS providers shall not bill for any reassessment that was not assigned unless communicated and approved by DSDS. Additional information regarding reassessment reimbursement rates and claim filing is included on the Provider Reassessment Information page.

Confidentiality

HCBS providers involved in the reassessment process gather personal and confidential information regarding HCBS participants to determine the continued eligibility and need for HCBS. HCBS providers shall keep all protected health information (PHI) confidential and shall only use PHI to perform functions, activities or services related to the delivery of HCBS. All PHI must be exchanged securely. When communicating with DSDS by email, HCBS providers shall utilize the Proofpoint Email Encryption software available through DSDS.

Policy Fundamentals

HCBS providers enrolled as a reassessment providers shall ensure their reassessors have, in addition to this policy, a thorough working knowledge of all applicable HCBS policies to include but not limited to:

  • Eligibility components
    • Medicaid
    • Nursing Facility Level of Care (LOC)
  • All HCBS available for authorization
    • State Plan (Agency)
    • State Plan Residential Care Facility (RCF)/Assisted Living Facility (ALF)
    • State Plan (Consumer Directed Services (CDS)
    • Adult Day Care Waiver (ADCW)
    • Aged and Disabled Waiver (ADW)
    • Independent Living Waiver (ILW)
    • Structured Family Caregiving Waiver (SFCW)
    • Brain Injury Waiver (BIW)
  • Understanding of the PCCP process
  • Case Record Documentation
  • Safety and Special Accommodations
  • Identification and mandated reporting of potential abuse, neglect and/or exploitation
  • Participant’s electronic case record functionality
    • Updating demographics:
      • Address, county and phone number(s)
      • Primary Language
      • Marital Status/Living Arrangement
    • Physician Information added as a contact
    • Adding a reassessment
    • Completion of the InterRAI HC
    • Enter the requested PCCP
    • Adding Case Notes
    • Adding Attachments
    • Manage Household
      • Select if participant resides with others

Reassessment Preparation

Standardized criteria are applied to determine the assignment of monthly reassessments. Assigned Reassessments will be accessed using the electronic case record system and HCBS providers shall be granted access to obtain their reassessments. Only those assigned to the HCBS provider by DSDS are to be completed. HCBS providers shall review their assigned reassessments monthly to identify changes.

If a provider has been assigned a reassessment and has experienced a PCCP update leading to a provider change or multiple providers, the HCBS provider may still complete the reassessment if the participant agrees. HCBS providers will be reimbursed for the completed reassessment as long as it has been assigned to them.

If the HCBS provider chooses not to complete an assigned reassessment, they must immediately notify the DSDS Provider Reassessment Review Team by selecting the action ‘unable to complete’ and reason ‘unable to complete the assessment’ in the month in which they receive their assigned reassessment and/or as soon as the decision is made not to complete it.

HCBS providers shall check the Medicaid Eligibility (ME) Code in the participant’s electronic case record to ensure the participantis eligible for a reassessment and reauthorization of services. When the HCBS provider reassessor identifies a potential Medicaid eligibility problem, the HCBS provider reassessor shall not complete the reassessment. The action ‘unable to complete’ and the reason ‘inactive Medicaid’ shall be selected.

  • Individuals enrolled in a Managed Care Health Plan ME code other than E2 (e.g. 05) are not eligible to receive HCBS authorized by DSDS.
  • If the participant is a Medicaid spenddown recipient, spenddown must be met at least once within the last three (3) months to remain eligible for HCBS.

The DSDS Provider Reassessor Review Team (PRR) must always be notified immediately of any identified circumstances that prevent the completion of assigned reassessments.

Case History

After the assigned reassessments have been reviewed and Medicaid eligibility has been established, HCBS providers shall review the participant’s case history. HCBS providers shall determine if there were changes to the previous authorization period that would need to be addressed and documented during the reassessment visit, e.g. changes in mental status that would impact the ability to self-direct for CDS participants. This review includes the following:

Note: The case record shall be reviewed for any care plan change requests that are pending. The HCBS provider reassessor shall discuss the requests with the participant and make the necessary updates to the care plan.

When the provider reassessor will not have a portable computer device or internet connectivity in the participant’s home, they shall take copies of the participant’s most recent (re)assessment and the current care plan to review and update during the face-to-face visit. These materials can be printed from the electronic case record.

The reassessment dates entered shall reflect the date of the actual face-to-face visit. If the reassessment is not completed on the same day, the date the reassessment isfully completed shall be entered in Section T of the InterRAI HC. Additional instructions for portions of the InterRAI HC can be found below.

Section A: Goal  – During the reassessment process, the HCBS provider reassessor shall work with the participant to review and update their goal for HCBS and ensure the PCCP works toward supporting the goal when possible. Any barriers that may prevent the goal from being achieved shall be documented.

An appropriate goal shall reflect what the participant hopes to achieve. The HCBS provider shall encourage the participant to express a goal in their own words, which may reflect:

  • I want to be living on my own and retain my independence.
  • I would like to ensure I have consistent help available to help with my day to day needs. A goal shall not be a statement of fact such as:
    • I want to continue to receive services.
    • I don’t know, or I’m really not sure.

Goals may come from the participant or legal representative. In the rare circumstance when a participant cannot verbalize a goal, a primary unpaid caregiver may provide the goal for the participant. Thorough case note documentation would be required in these rare instances. Case note documentation shall include:

  • The participant is unable to express a goal
  • Who the goal was provided by (the legal guardian or primary unpaid caregiver)
  • Name and relationship of the person providing the goal

Section S: Backup Plan - The HCBS provider reassessor shall review and ask the participant and/or legal guardian for details of their backup plan to be used when events such as weather or sickness prevent service delivery by their HCBS provider(s). If the aide or attendant is not available, the participant and/or legal guardian shall provide a support system to ensure needs are met and continuation of services. Available assistance may vary, but all availability should be considered.

The backup plan shall identify a specific individual(s) available to assist when needed and may consist of the following:

  • Family, friends, a neighbor, collateral contacts, etc.

A brief detailed summary of the support shall be provided and documented in the participant’s electronic case record and include:

  • The name, phone number and relationship of the individual providing the support
  • The specific task(s) to be provided
  • The frequency of each task being provided (e.g., all meals prepared Monday, Wednesday and Friday, bathing Tuesday and Thursday)

Note: If multiple supports are identified, HCBS provider reassessors shall ensure all contact information, specific tasks, and the frequency of each task is documented specifically for each individual providing the support.

911 should only be used in rare instances 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 identified.

Section T: Assessment Information (Signature) – The signature area in Section T of the InterRAI shall include the provider reassessors signature.

The provider reassessor shall determine if there is a newly appointed legal guardian. If a newly appointed legal guardian has been identified, the HCBS provider reassessor shall update the information in the participant’s electronic case record. The HCBS provider reassessor shall attempt to obtain copies of the guardianship paperwork and attach them in the participant’s electronic case record. When these attempts are unsuccessful, the HCBS provider reassessor shall document this in case notes.

Person Centered Care Plan Development

An essential component of a quality reassessment process is the development of a PCCP. All PCCPs developed by the HCBS provider reassessor are completed in a ‘requested’ status and require review and approval by DSDS. Therefore, HCBS provider reassessors shall ensure that all requested PCCPs are:

  • Supported by a thorough, well documented reassessment, and associated case notes that identify functioning problems, current resources (formal and informal), and unmet needs
  • Developed with the participant and/or authorized representative to address identified unmet needs while being supportive of the right to self-determination
  • Developed within the guidelines of HCBS programmatic policies
  • Built on the participant's unmet needs without duplicating current formal and informal supports

During the annual reassessment the HCBS provider reassessor shall determine the participant’s satisfaction with the HCBS they receive and document the participant’s satisfaction in case notes.

Collateral Contacts

When additional information is needed to assist in PCCP development and coordinate care for the participant, collateral contacts (an individual familiar with the needs of the participant) shall be made by the HCBS provider reassessor. These contacts shall not compromise the rights and confidentiality of the participant. Possible resources to assist in the PCCP development may include formal and/or informal supports:

Service/Tasks Guidelines

The PCCP identifies the services and tasks based on the participant’s needs. The HCBS authorized under the PCCP shall provide reinforcement and enhancement to the current support system of the participant

Authorized HCBS shall not replace or duplicate existing formal or informal support. It is not appropriate to recommend certain HCBS when the participant lives with other person(s) who are able to perform those services or tasks. The following shall be taken into consideration when developing a PCCP:

  • The aide’s or attendant’s ability to perform multiple tasks within the same timeframe
  • Size of the participant’s living area
  • Assistance provided by others in the household
  • Space/Tasks shared with others residing in the household
  • Assistance provided by other formal and informal supports
  • Meal preparation
  • Cleaning
  • Availability of laundry facilities

Note: Assistance with meal preparation based on preference (e.g. eating at different times or prefer different foods) shall not be authorized for participants that 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.

When authorizing CDS Essential Transportation, there must be an identified need for personal care assistance even if that need is met by supports other than CDS. Personal care does not need to be performed while Essential Transportation is being conducted.

CDS Transportation does not include transporting to medical appointments when those appointments are covered under the MO HealthNet Non-Emergency Medical Transportation (NEMT) program. To determine if NEMT covers the medical appointment and to determine availability, contact the NEMT provider at 1-866- 269-5927. For more information regarding NEMT, visit the Department of Social Services webpage.

The In-Home Services Worksheet/Instructions and/or CDS Worksheet/Instructions may be used as a tool to temporarily develop the PCCP. The worksheets assist in the development of a more uniform and consistent approach when determining the appropriate amount of services necessary to meet a participant's unmet needs. The worksheets are designed to provide information identifying suggested times and frequencies to be considered with the care needs of the participant in mind.

Note: HCBS provider reassessors shall utilize the CDS Worksheet and/or In-Home Services Worksheet to include justifications of tasks when completing an Independent Living Waiver (ILW) reassessment. The completed worksheet(s) shall be placed in the participant's electronic case record for review by the DSDS Provider Reassessor Review Team

Upon completion of the PCCP development, the HCBS provider shall enter and submit the PCCP in the participant’s electronic case record. The pending PA shall include accurate provider selection. Instructions are located in the electronic case record user guide.

COOP Priority

A COOP priority risk indicator must be determined during the reassessment process and entered in the participant’s electronic case record. This indicator is 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. To determine the level of risk, the HCBS provider reassessor shall evaluate the participant’s circumstances (i.e., support system, cognitive ability, and noncompliance) and the importance of service delivery during any staffing shortage.

The 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 the risk. A fragile, unreliable or insufficient support system must be documented in case notes justifying risk status.

Forms

Forms are to be completed per HCBS policies and specific programmatic requirements. Should the participant have a legal guardian, it is necessary to obtain the legal guardian’s signature on official forms/documents. It may also be necessary to obtain signatures from authorized representatives (Medical Durable Power of Attorney, etc.). In addition to the reassessor, forms shall only be signed by the participant, legal guardian, or authorized representative.

The provider reassessor shall have two (2) copies of each form and obtain the appropriate signatures on both copies. The provider reassessor shall keep one copy of the signed form and the additional copy shall be provided to the participant, legal guardian, or authorized representative. If a participant is unable to understand the information in the forms presented and does not have a legal guardian or authorized representative, a case note shall be made stating why a signature could not be obtained.

Additional forms may be required dependent on the situations specific to the participant. The forms shall be attached in the participant’s electronic case record upon completion of the reassessment. Such forms may include, but are not limited to:

Case Notes Documentation

The participant’s electronic case record must contain all documentation involving the participant. All contacts made and actions regarding a participant’s HCBS shall be electronically recorded. Case notes summarize the participant’s circumstances, justify the actions taken and provide a record of the interaction between the participant, collateral contacts and HCBS providers. The Case Record Documentation Policy and the Case Record Documentation Quick Guide should be utilized to ensure all appropriate documentation is completed for all case actions.

To facilitate effective communication provider reassessors shall include in their case note signature and their email address associated with the agency, or an agency email address that would be best for the provider reassessor to be contacted. Personal email addresses should not be used. Case notes shall not be entered or signed by any other individuals employed with the provider.

Identification of Adverse Action

Any action that adversely affects the request for, or amount of, authorized HCBS shall be communicated to DSDS and documented thoroughly in case notes. HCBS provider reassessors shall be aware of the following actions that would adversely affect HCBS:

  • Reduction of HCBS
  • Closing of an HCBS
  • No documented need
  • LOC not met
  • Inability to self-direct
  • Entering a facility
  • Non-compliant
  • Program eligibility
  • Threatening behavior
  • Unable to locate the participant
  • HCBS provider reassessors shall educate the participant of the potential adverse action and provide DSDS with the necessary information and documentation when a change to the participant's HCBS adversely affects the PCCP. DSDS requires the following information to determine if an adverse action is to be initiated.
  • Case notes
    • Documentation shall provide a clear explanation of a needed adverse action.
    • Document the conversation was held with the participant and if they agree or disagree with the changes being made to the care plan.
  • Forms (when applicable)
    • St. Louis University Mental Status (SLUMS)
    • Self-Direction Assessment Questions

Upon review of the information submitted, DSDS will contact HCBS providers for additional information if necessary.

Finalization and Submission

HCBS reassessments and corresponding documentation shall be entered into the participant’s electronic case record within five (5) business days of the reassessment. All reassessments not submitted by the last calendar day of the month on which the reassessment is due will automatically be electronically returned to the DSDS PRR Team. Weekends, holidays, and/or office closures do not affect the due date.

HCBS Provider Review and Submission

Prior to submitting a reassessment, the HCBS provider reassessor shall review and ensure all documentation and information is present in the participant’s electronic case record. Provider reassessors shall ensure:

  • All necessary forms are attached
  • Selection of appropriate tasks
  • Appropriate HCBS provider is selected
  • Case note documentation is clear and accurate
  • The reassessment and PCCP are entered correctly and in pending status
  • Collateral contacts are entered and updated in the participant's electronic case record

Upon verifying the appropriate documentation and information has been entered, choose the ‘Submit Care Plan for Review’ action to notify the PRR Team.

DSDS Review and Remediation

The DSDS PRR Team will review each reassessment and the PCCP, ensuring all information is complete and accurate, and that all requirements are met. The review will also consist of the following:

  • The authorization of units and cost of the PCCP
  • Documentation justifies the pending PCCP
  • Provider selection

Reassessments found to be inadequate and/or incomplete by the DSDS Provider Reassessor Review Team includes:

  • Insufficient documentation and/or information
  • DSDS PRR Team has not been notified of an entry of a reassessment by the last calendar day of the month prior to when the reassessment is due
  • DSDS PRR Team has not been notified of the inability to complete a reassessment by the last calendar day of the month prior to when the reassessment is due

When the DSDS PRR Team determines the reassessment, PCCP and/or documentation are inadequate, the HCBS provider will be contacted for remediation. To ensure sufficient time for review and approval of the reassessment, the HCBS provider shall have three (3) business days to complete the remediation and notify the DSDS PRR Team of its completion. If the HCBS provider reassessor is not available to complete the necessary remediation, the provider agency must ensure completion by the required timeframe.

Approval of the PCCP

The HCBS provider shall check the participant’s electronic case record to access information related to each participant’s reassessment and PCCP approval status. The HCBS provider should notify the DSDS PRR Team through encrypted email of any questions or concerns regarding a reassessment or PCCP at ProviderReassessmentReview@health.mo.gov. 

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