Revision 09-1

 

 

§47.41 Allowable Tasks

 

The PHC Program includes the following tasks:

(1) personal care tasks related to the care of the individual's physical well being, including:

(A) bathing, which is:

(i) drawing water in sink, basin, or tub;

(ii) hauling or heating water;

(iii) laying out supplies;

(iv) assisting in or out of tub or shower;

(v) sponge bathing and drying;

(vi) bed bathing and drying;

(vii) tub bathing and drying; and

(viii) providing standby assistance for safety;

(B) dressing, which is:

(i) dressing the individual;

(ii) undressing the individual; and

(iii) laying out clothes;

(C) meal preparation, which is:

(i) cooking a full meal;

(ii) warming up prepared food;

(iii) planning meals;

(iv) helping prepare meals; and

(v) cutting client's food for eating;

(D) feeding/eating, which is:

(i) spoon-feeding;

(ii) bottle-feeding;

(iii) assisting with using eating and drinking utensils and adaptive devices, not including tube feeding; and

(iv) providing standby assistance or encouragement;

(E) exercise, which is walking with the individual;

(F) grooming, shaving, or oral care, which is:

(i) shaving;

(ii) brushing teeth;

(iii) shaving underarms and legs, when requested;

(iv) caring for nails; and

(v) laying out supplies;

(G) routine hair or skin care, which is:

(i) washing hair;

(ii) drying hair;

(iii) assisting with setting, rolling, or braiding hair, not including styling, cutting, or chemical processing of hair;

(iv) combing or brushing hair;

(v) applying nonprescription lotion to skin;

(vi) washing hands and face;

(vii) applying makeup; and

(viii) laying out supplies;

(H) assistance with self-administered medications, which is assistance with medication as defined in §97.2(11) of this title (relating to Definitions);

(I) toileting, which is:

(i) changing diapers;

(ii) changing colostomy bag or emptying catheter bag;

(iii) assisting on or off bedpan;

(iv) assisting with the use of a urinal;

(v) assisting with feminine hygiene needs;

(vi) assisting with clothing during toileting;

(vii) assisting with toilet hygiene, including the use of toilet paper and washing hands;

(viii) changing external catheter;

(ix) preparing toileting supplies and equipment, not including preparing catheter equipment; and

(x) providing standby assistance; and

(J) transfer, which is:

(i) non-ambulatory movement from one stationary position to another, not including carrying;

(ii) adjusting or changing the individual's position in a bed or chair (positioning);

(iii) assisting in rising from a sitting to a standing position;

(K) ambulation, which is:

(i) assisting in positioning for use of a walking apparatus;

(ii) assisting with putting on and removing leg braces and prostheses for ambulation;

(iii) assisting with ambulation or using steps;

(iv) assisting with wheelchair ambulation; and

(v) providing standby assistance;

(2) home management tasks that support the individual's health and safety, including:

(A) cleaning, which is:

(i) cleaning up after the individual's personal care tasks;

(ii) emptying and cleaning the individual's bedside commode;

(iii) cleaning the individual's bathroom;

(iv) changing the individual's bed linens and making the individual's bed;

(v) cleaning floor of living areas used by the individual;

(vi) dusting areas used by the individual;

(vii) carrying out the trash and setting out garbage for pick up;

(viii) cleaning stovetop and counters;

(ix) washing the individual's dishes; and

(x) cleaning refrigerator and stove;

(B) laundry, which is:

(i) doing hand wash;

(ii) gathering and sorting;

(iii) loading and unloading machines in residence;

(iv) using laundromat machines;

(v) hanging clothes to dry;

(vi) folding and putting away clothes; and

(C) shopping, which is:

(i) preparing a shopping list;

(ii) going to the store and purchasing or picking up items;

(iii) picking up medication; and

(iv) storing the individual's purchased items; and

(3) escorting, including:

(A) accompanying the individual outside the home to support the individual in living in the community;

(B) arranging for transportation, not including direct individual transportation;

(C) accompanying the individual to a clinic, doctor's office, or location for medical diagnosis or treatment; and

(D) waiting in the doctor's office or clinic with an individual if necessary due to client's condition or distance from home.

 

§47.43 Referrals

 

(a) A provider must:

(1) accept all DADS referrals for services under the PHC Program; and

(2) conduct the pre-initiation activities as described in §47.45 of this chapter (relating to Pre-Initiation Activities).

(b) There are two methods of referral:

(1) For expedited referrals, the case manager makes the referral by oral notice and on DADS' authorization for community care services form.

(2) For routine referrals, the case manager makes the referral on DADS' authorization for community care services form.

 

§47.45 Pre-Initiation Activities

 

(a) Pre-initiation activities. A supervisor must complete the following activities for each referral.

(1) The supervisor must conduct an evaluation.

(A) The evaluation must be a single document that includes the individual's self-report of:

(i) the dates and reasons for any hospitalization within the last three months; and

(ii) the assistance needed for the individual to perform ADLs, including any assistive devices or medical equipment used by the person.

(B) If the provider determines during the evaluation that the individual exhibits reckless behavior that results in imminent danger to the health and safety of the individual or provider staff, the provider must convene an Interdisciplinary Team meeting as described in §47.49 of this chapter (relating to Interdisciplinary Team) to discuss the barriers to service delivery.

(2) The supervisor must develop a service delivery plan on a single document that:

(A) is agreed upon and signed by the individual and the provider;

(B) indicates the location of service delivery;

(C) records the following:

(i) the tasks which the individual is authorized to receive;

(ii) the total weekly hours of service DADS authorizes the individual to receive;

(iii) the service schedule, which must include as necessary, based on an individual’s needs, certain time periods for the delivery of specified tasks;

(iv) frequency of supervisory visits; and

(v) a statement that:

(I) the PHC Program only provides the tasks allowable in the program as described in §47.41 of this chapter (relating to Allowable Tasks) and agreed to on the service delivery plan; and

(II) the provider is not responsible for meeting the applicant's needs other than tasks allowed under the PHC Program.

(3) The provider must obtain a complete practitioner's statement and submit for DADS' review as described in §47.47 of this chapter (relating to Medical Need Determination). This paragraph does not apply to FC services.

(A) For routine referrals:

(i) send a copy of the practitioner’s statement to DADS by facsimile or secured email; or

(ii) mail a copy of the practitioner’s statement to DADS.

(B) For expedited referrals:

(i) DADS may send the authorization for community services form pending receipt of the practitioner’s statement if the provider notifies DADS that the provider has received a complete practitioner’s statement that documents the individual’s medical condition is the cause of the individual’s functional impairment.

(ii) Upon notification of a completed practitioner’s statement, DADS and the provider will negotiate a start-of-care date.

(iii) The provider must send the complete practitioner’s statement to DADS within 7 working days after service initiation.

(iv) If a complete practitioner’s statement is not sent to DADS within 7 working days after service initiation the provider is not entitled to payment from DADS until the date DADS receives the completed practitioner’s statement. In this circumstance, DADS will change the service initiation date to the date DADS receives the completed practitioner’s statement.

(v) The signature date of the practitioner must be on or before the negotiated start-of-care date.

(b) Service delivery plan variances.

(1) The provider must notify the case manager of a variance in the service delivery plan when the initial service delivery plan developed by the provider:

(A) has more hours than authorized on DADS' authorization for community care services form;

(B) has no personal care services, except for FC services; or

(C) is temporarily changed as described in paragraph (3) of this subsection.

(2) The provider must provide services according to the existing service delivery plan, until the provider receives a new DADS' authorization for community care services form, except the provider may temporarily change the service delivery plan if:

(A) the individual requests and requires temporary assistance with allowable tasks not identified on the service delivery plan due to a change in circumstances or available supports; and

(B) the change in tasks does not increase the total approved hours of service or continue for more than 60 days.

(3) The provider must request and obtain a new DADS authorization for community services form when a temporary variance in tasks on the service delivery plan is to continue for more than 60 days or would result in more hours of service provided than have been approved.

(4) The provider must request a new DADS authorization for community care services form before a temporary variance from the service delivery plan continues for more than 60 days.

(5) The provider must maintain the following documentation regarding the temporary service delivery plan variance in the individual's file:

(A) the specific variance in the service delivery plan;

(B) the duration of the temporary variance; and

(c) the reason for the temporary variance as described in paragraph (3) of this subsection.

(c) Pre-initiation activities due date. The provider must complete the pre-initiation activities as follows:

(1) for routine referrals, within 14 days after one of the following dates, whichever is later:

(A) the referral date on DADS' authorization for community care services form; or

(B) the date the provider receives DADS' authorization for community care services form, unless the provider fails to stamp the receipt date on the form, in which case the referral date will be used to determine timeliness; and

(2) for expedited referrals, by the date negotiated between the case manager and provider, which must be less than 14 days after the oral request.

(d) Delay in pre-initiation activities.

(1) A provider may delay meeting the due dates in subsection (c) of this section only for reasons beyond its control such as natural or other disasters. The provider must continue efforts to complete pre-initiation activities and set a date, if possible, for completion of pre-initiation activities.

(2) The provider must document any failure to complete the pre-initiation activities for routine referrals by the due date, including:

(A) the reason for the delay, which must be beyond the provider’s control;

(B) either the date the provider anticipates it will complete the pre-initiation activities or specific reasons why the provider cannot anticipate a completion date; and

(C) a description of the provider's ongoing efforts to complete pre-initiation activities.

(3) The provider must notify the case manager of any failure to complete the pre-initiation activities for expedited referrals before the negotiated date for completion of pre-initiation activities. The case manager may refer the individual to another provider.

(e) Documentation of pre-initiation activities.

(1) The provider may combine the evaluation and service delivery plan into a single document, but each item must be clearly identifiable.

(2) The provider must maintain documentation of the pre-initiation activities in the individual's file.

 

§47.47 Medical Need Determination

 

(a) Applicability. This section does not apply to FC services or transfers of individuals in the PHC Program.

(b) Determining medical need. A provider must obtain and submit a complete practitioner's statement to DADS for review by the applicable due date, as described in §47.45(c) of this chapter, (relating to Pre-Initiation Activities) for:

(1) an individual whom DADS refers to the provider (unless the individual requests and is to receive FC services);

(2) an individual currently receiving FC services whom DADS refers to the provider for PHC services or CAS; and

(3) an individual currently receiving services whom DADS refers to the provider to have medical need reassessed, as requested by the case manager, such as when the initial medical need was established for a limited time.

(c) Submitting a practitioner's statement. A provider must submit a complete practitioner's statement to:

(1) the DADS case manager for PHC services; and

(2) the DADS regional nurse for CAS.

(d) Reinstatement of services after termination. If DADS notifies the provider that services are terminated, all pre-initiation activities, including medical need determination, must be completed before services are reinstated.

(e) Mental illness and mental retardation. Persons diagnosed with mental illness, mental retardation, or both, are not considered to have established medical need based solely on such diagnoses, but may establish medical need through a related diagnosis that results in a functional limitation.

 

§47.49 Interdisciplinary Team

 

(a) Interdisciplinary Team (IDT). The IDT is a designated group that includes the following people who meet when the provider identifies the need to discuss service delivery issues or barriers to service delivery:

(1) the individual or the individual's representative, or both;

(2) a provider representative; and

(3) a DADS representative, who may be:

(A) the case manager (or designee);

(B) the case manager's supervisor (or designee);

(C) the contract manager (or designee); or

(C) the regional nurse (or designee).

(b) Convening an IDT meeting.

(1) The provider must convene an IDT meeting:

(A) within three working days of the date the provider suspends services to an individual under §47.71(a)(7) or (b) of this chapter (relating to Suspensions); or

(B) within seven working days of the date the provider identifies an issue that prevents the provider from carrying out a requirement of the PHC Program.

(2) A provider must make and document a good faith effort to include all members of the IDT described in subsection (a) of this section.

(3) If the provider is unable to convene an IDT meeting with all the members described in subsection (a) of this section, the provider must convene the IDT meeting with the available members and send the documentation of the IDT meeting described in subsection (e) of this section to the Regional Director for the DADS region in which the individual resides. The documentation must be sent within five working days after the date of the IDT meeting.

(c) IDT meeting.

(1) The IDT meeting may be conducted by telephone or in person.

(2) The IDT must:

(A) evaluate the issue;

(B) identify any solutions to resolve the issue; and

(C) make recommendations to the provider.

(d) IDT meeting outcome. The provider must do one of the following within two working days after the IDT meeting:

(1) implement the recommendations of the IDT; or

(2) discharge the individual from the provider and refer the individual to the case manager for referral to another provider.

(e) Documentation of the IDT meeting. The provider must document the IDT meeting in the individual's file, including the:

(1) specific reasons for calling the IDT meeting;

(2) participants in the IDT meeting;

(3) recommendations of the IDT;

(4) action as a result of the IDT recommendations; and

(5) reasons for the provider's actions.