Chapter 5160-50 Transitions carve-out waiver

5160-50-02 Transitions carve-out waiver program: eligibility and enrollment.

(A) Enrollment on the transitions carve-out waiver is available only to individuals who, on the effective date of this rule, were enrolled on the Ohio home care waiver or are participating in the HOME choice (helping Ohioans move, expanding choice) demonstration program. Transfer from the Ohio home care waiver to the transitions carve-out waiver will occur after ODM or its designee determines the criteria in paragraphs (B) and (C) are met.

(B) To be eligible for enrollment in the transitions carve-out waiver program, an individual must meet all of the following requirements:

(1) Be age sixty or older;

(2) Be determined eligible for Ohio medicaid in accordance with rules 5160:1-2- 01.6 and 5160:1-3-24 of the Administrative Code;

(3) Participate in an assessment to determine if the individual has needs that can be met through the transitions carve-out waiver program;

(4) Be determined to have a nursing facility (NF) -based level of care (i.e., intermediate or skilled) in accordance with rule 5160-3-08 of the Administrative Code;

(5) In the absence of the transitions carve-out waiver program, require hospitalization or institutionalization in a NF to meet his or her needs;

(6) Be determined to require and agree to receive at least one waiver service monthly that is otherwise unavailable through another source (including, but not limited to, private pay, community resources and/or the medicaid state plan) in an amount sufficient to meet the individual's assessed needs;

(7) Be able to establish residency in a place that is not a hospital, NF, intermediate care facility for individuals with an intellectual disability (ICF-IID) or another licensed/certified facility, any facility covered by section 1616(e) of the Social Security Act ( 42 U.S.C. 1382(e) (March 2, 2004)), residential care facility, adult foster home or another group living arrangement subject to state licensure or certification.

(8) Sign an agreement prior to waiver enrollment confirming that the individual has been informed of service alternatives, choice of qualified providers available in the transitions carve-out waiver program and the options of institutional and community-based care, and he or she elects to receive transitions carve-out waiver services; and

(9) Have needs that can be safely met through the transitions carve-out waiver in a home or community setting as determined by ODM or its designee.

(C) Subject to paragraph (H) of this rule, to be enrolled and maintain enrollment in the transitions carve-out waiver program, an individual must be determined by ODM or its designee to meet all of the following requirements:

(1) Be determined eligible for the transitions carve-out waiver program in accordance with paragraph (B) of this rule;

(2) Not reside in a hospital, NF, intermediate care facility for individuals with an intellectual disability (ICF-IID) or another licensed/certified facility, any facility covered by section 1616(e) of the Social Security Act ( 42 U.S.C. 1382(e) (March 2, 2004)), residential care facility, adult foster home or another group living arrangement subject to state licensure or certification.

(3) Have his or her health and welfare assured while enrolled on the waiver;

(4) Participate in the development and implementation of a person-centered all services plan, and consent to the plan by signing and dating it;

(5) Agree to and receive case management services from ODM or its designee including, but not limited to:

(a) Annual and other assessments, as needed,

(b) Home safety evaluations,

(c) Contact with the case manager and/or the individual's team members, including, but not limited to telephone communications, and face-to-face and in-home visits; and

(6) Agree to and participate in quality assurance and participant satisfaction activities during his or her enrollment on the transitions carve-out waiver program including, but not limited to, face-to-face visits.

(D) If an individual fails to meet any of the requirements set forth in paragraph (B) and/or paragraph (C) of this rule, the individual shall be denied enrollment on the transitions carve-out waiver program.

(E) Once enrolled on the transitions carve-out waiver program, an individual's NF level of care shall be reassessed at least annually, and more frequently if there is a significant change in the individual's situation that may impact his or her health and welfare. If the reassessment determines the individual no longer meets the requirements set forth in paragraph (B) and/or paragraph (C) of this rule, he or she shall be disenrolled from the transitions carve-out waiver program.

(F) If, at any other time, it is determined that an individual enrolled on the transitions carve-out waiver program no longer meets the requirements set forth in paragraph (B) and/or paragraph (C) of this rule, he or she shall be disenrolled from the transitions carve-out waiver program. Reassessment pursuant to paragraph (E) is not required to make this determination.

(G) If an individual is denied enrollment in the transitions carve-out waiver program pursuant to paragraph (D) of this rule, or is disenrolled from the waiver pursuant to paragraph (E) or (F) of this rule, the individual shall be afforded notice and hearing rights in accordance with division 5101:6 of the Administrative Code.

(H) The number of individuals enrolled in the transitions carve-out waiver shall not exceed the centers for medicare and medicaid services (CMS) -authorized limit for the waiver program year.

Replaces: 5160-50-02 and 5160-50- 02.1

Effective: 12/1/2014
Five Year Review (FYR) Dates: 12/01/2019
Promulgated Under: 119.03
Statutory Authority: 5166.02
Rule Amplifies: 5164.02 , 5162.03
Prior Effective Dates: 4/4/77, 12/21/77, 6/1/80, 5/1/87, 4/1/88, 5/15/89, 3/12/92 (Emer), 6/1/92, 7/31/92 (Emer), 10/30/92, 4/30/93 (Emer), 7/30/93, 7/1/98, 9/29/00, 3/1/02 (Emer), 5/30/02, 7/1/06, 7/1/08

5160-50-02.1 [Rescinded] Transitions carve-out waiver: eligibility criteria for time-limited enrollment of HOME choice ("Helping Ohioans Move, Expanding Choice") demonstration program participants.

Effective: 12/1/2014
Five Year Review (FYR) Dates: 09/05/2014
Promulgated Under: 119.03
Statutory Authority: 5166.02
Rule Amplifies: 5164.02 , 5162.03 , 5166.02 , 5166.10 , 309.30.70 of
Am. Sub HB 119, 127th G.A.
Prior Effective Dates: 7/1/08

5160-50-04 Transitions carve-out waiver: definitions of the covered services and provider requirements and specifications.

This rule sets forth the definitions of the services covered by the transitions carve-out waiver. This rule also sets forth the provider requirements and specifications for the delivery of transitions carve-out waiver services. The services are reimbursed in accordance with rule 5101:3-50-06 of the Administrative Code.

(A) Waiver nursing services.

(1) "Waiver nursing services" are defined as services provided to transitions carve-out waiver consumers that require the skills of a registered nurse (RN) or licensed practical nurse (LPN) at the direction of an RN. All nurses providing waiver nursing services to consumers on the transitions carve-out waiver shall provide services within the nurse's scope of practice as set forth in Chapter 4723. of the Revised Code and Administrative Code rules adopted thereunder, and shall possess a current, valid and unrestricted license with the Ohio board of nursing.

(2) "Personal care aide services" as defined in paragraph (B) of this rule may be reimbursed as waiver nursing services when provided incidental to waiver nursing services as defined in paragraph (A)(1) of this rule and performed during the authorized waiver nursing visit.

(3) Waiver nursing services do not include:

(a) Services delegated in accordance with Chapter 4723. of the Revised Code and rules to be adopted thereunder, and to be performed by individuals who are not licensed nurses in accordance with Chapter 4723. of the Revised Code;

(b) Services that require the skills of a psychiatric nurse;

(c) Visits performed for the sole purpose of meeting the supervisory requirements as set forth in paragraph (B)(6)(c) of this rule;

(d) Visits performed for the sole purpose of conducting an "OASIS"(outcome and assessment information set) assessment or any other assessment;

(e) Visits performed for the sole purpose of meeting the home care attendant service nurse consultation requirements set forth in rules 5101:3-46-04.1 and 5101:3-50-04.1 of the Administrative Code; or

(f) Services performed in excess of the number of hours approved pursuant to, and as specified on, the consumer's all services plan.

(4) In order to be a provider and submit a claim for reimbursement of waiver nursing services, the RN, or LPN at the direction of the RN, delivering the service must meet the following requirements:

(a) Comply with all applicable rules set forth in Chapters 5101:3-45 and 5101:3-50 of the Administrative Code.

(b) Request reimbursement for the provision of services in accordance with rule 5101:3-50-06 of the Administrative Code.

(c) Be employed by a medicare-certified, or otherwise-accredited home health agency, or be a non-agency home care nurse provider .

(d) Not be the consumer's legally responsible family member as that term is defined in rule 5101:3-45-01 of the Administrative Code, unless the legally responsible family member is employed by a medicare-certified, or otherwise-accredited home health agency .

(e) Not be the foster caregiver of the consumer .

(f) Be identified as the provider and have specified on, the consumer's all services plan that is prior-approved by ODJFS or its designee, the number of hours for which the provider is authorized to furnish waiver nursing services to the consumer.

(g) Be identified as the provider on, and be performing nursing services pursuant to the consumer's plan of care, as that term is defined in rule 5101:3-45-01 of the Administrative Code. The plan of care must be signed and dated by the consumer's treating physician.

(h) Be providing the service for one individual, or for up to three individuals in a group setting, during a face-to-face nursing visit.

(5) Non-agency LPNs, at the direction of an RN, must:

(a) Conduct a face-to-face visit with the directing RN at least every sixty days after the initial visit to evaluate the provision of waiver nursing services and LPN performance, and to assure that waiver nursing services are being provided in accordance with the approved plan of care; and

(b) Conduct a face-to-face visit with the consumer and the directing RN before initiating services and at least every one hundred twenty days for the purpose of evaluating the provision of waiver nursing services, the consumer's satisfaction with care delivery, and LPN performance, and to assure that waiver nursing services are being provided in accordance with the approved plan of care.

(6) All waiver nursing service providers must maintain a clinical record for each consumer served in a manner that protects the confidentiality of these records. Medicare-certified, or otherwise-accredited home health agencies, must maintain the clinical records at their place of business. Non-agency waiver nursing service providers must maintain the clinical records at their place of business, and maintain a copy in the consumer's residence. For the purposes of this rule, the place of business must be a location other than the consumer's residence. At a minimum, the clinical record must contain the information listed in paragraphs (A)(6)(a) to (A)(6) (l) of this rule.

(a) Consumer identifying information, including but not limited to: name, address, age, date of birth, sex, race, marital status, significant phone numbers, and health insurance identification numbers.

(b) Consumer medical history.

(d) A copy of the initial and all subsequent all services plans.

(e) A copy of the initial and all subsequent plans of care, specifying the type, frequency, scope and duration of the nursing services being performed. When services are performed by an LPN at the direction of an RN, the clinical record shall include documentation that the RN has reviewed the plans of care with the LPN. The plan of care must be recertified by the treating physician every sixty days, or more frequently if there is a significant change in the consumer's condition.

(f) In all instances when the treating physician gives verbal orders to the nurse, the nurse must document, in writing, the physician's orders, the date and time the orders were given, and sign the entry in the clinical record. The nurse must subsequently secure documentation of the verbal orders, signed and dated by the treating physician.

(g) In all instances when a non-agency LPN is providing waiver nursing services, the LPN must provide clinical notes, signed and dated by the LPN, documenting the face-to-face visits between the LPN and the directing RN, and documenting the face-to-face visits between the LPN, the consumer and the directing RN. Nothing shall prohibit the use of technology-based systems in collecting and maintaining the documentation required by this paragraph.

(h) A copy of any advance directives including, but not limited to, "do not resuscitate" (DNR) order or medical power of attorney, if they exist.

(i) Documentation of all drug and food interactions, allergies and dietary restrictions.

(j) Clinical notes and other documentation of tasks performed or not performed, arrival and departure times, and the dated signatures of the provider and consumer or authorized representative, verifying the service delivery upon completion of service delivery. Nothing shall prohibit the collection and maintenance of documentation through technology-based systems. The consumer's or authorized representative's signature of choice shall be documented on the consumer's all services plan, and shall include, but not be limited to, any of the following: a handwritten signature, initials, a stamp or mark, or an electronic signature.

(k) Clinical notes, signed and dated by the nurse, documenting all communications with the treating physician and other members of the multidisciplinary team. Nothing shall prohibit the use of technology-based systems in collecting and maintaining the documentation required by this paragraph.

(l) A discharge summary, signed and dated by the departing nurse, at the point the nurse is no longer going to provide services to the consumer, or when the consumer no longer needs nursing services. The summary should include documentation regarding progress made toward goal achievement and indicate any recommended follow-ups or referrals.

(B) Personal care aide services.

(1) "Personal care aide services" are defined as services provided pursuant to the transitions carve-out waiver's all services plan that assist the consumer with activities of daily living (ADL) and instrumental activities of daily living (IADL) needs. If the consumer's all services plan states that the service provided is to be personal care aide services, the service shall never be billed as a nursing service. Personal care aide services consists of the services listed in paragraphs (B)(1)(a) to (B)(1)(e) of this rule. If the provider cannot perform IADLs, the provider must notify ODJFS or its designee, in writing, of the service limitations before inclusion on the consumer's all services plan.

(a) Bathing, dressing, grooming, nail care, hair care, oral hygiene, shaving, deodorant application, skin care, foot care, feeding, toileting, assisting with ambulation, positioning in bed, transferring, range of motion exercises, and monitoring intake and output;

(b) General homemaking activities, including but not limited to: meal preparation and cleanup, laundry, bed-making, dusting, vacuuming, and waste disposal;

(c) Household chores, including but not limited to washing floors, windows and walls, tacking down loose rugs and tiles; and moving heavy items to provide safe access and exit;

(d) Paying bills and assisting with personal correspondence as directed by the consumer; and

(e) Accompanying or transporting the consumer to transitions carve-out waiver services, medical appointments, other community services, or running errands on behalf of the consumer.

(2) Personal care aide services do not include services performed in excess of the number of hours approved pursuant to the all services plan.

(3) Personal care aides shall not administer prescribed or over-the-counter medications to the consumer, but may, unless otherwise prohibited by the provider's certification or accreditation status, pursuant to paragraph (C) of rule 4723-13-02 of the Administrative Code, help the consumer self-administer medications by:

(a) Reminding the consumer when to take the medication, and observing to ensure the consumer follows the directions on the container;

(b) Assisting the consumer by taking the medication in its container from where it is stored and handing the container to the consumer;

(d) Assisting a consumer who is physically-impaired, but mentally alert, in removing oral or topical medication from the container and in taking or applying the medication; and

(e) Assisting a consumer who is physically unable to place a dose of medication in his or her mouth without spilling or dropping it by placing the dose in another container and placing that container to the mouth of the consumer.

(4) Personal care aide services shall be delivered by one of the following:

(a) An employee of a medicare-certified, or otherwise-accredited home health agency; or

(b) A non-agency personal care aide.

(5) In order to be a provider and submit a claim for reimbursement, all individuals providing personal care aide services must meet the following:

(a) Comply with all applicable rules set forth in Chapters 5101:3-45 and 5101:3-50 of the Administrative Code.

(b) Request reimbursement for the provision of services in accordance with rule 5101:3-50-06 of the Administrative Code.

(d) Be identified as the provider, and have specified on, on the consumer's all services plan that is prior-approved by ODJFS or its designee, the number of hours for which the provider is authorized to furnish personal care aide services to the consumer.

(e) Have a valid social security number, and one of the following forms of identification:

(i) Alien identification,

(ii) State of Ohio identification,

(iii) A valid driver's license, or

(iv) Other government-issued photo identification .

(f) Not be the consumer's legally responsible family member as that term is defined in rule 5101:3-45-01 of the Administrative Code .

(g) Not be the foster caregiver of the consumer .

(h) Be providing personal care aide services for one individual, or for up to three individuals in a group setting during a face-to-face visit .

(i) Comply with the additional applicable provider-specific requirements as specified in paragraph (B)(6) or (B)(7) of this rule.

(6) Medicare-certified and otherwise-accredited agencies must assure that personal care aides meet the following requirements:

(a) Before commencing service delivery, the personal care aide must:

(i) Obtain a certificate of completion of either a competency evaluation program or training and competency evaluation program approved or conducted by the Ohio department of health under section 3721.31 of the Revised Code, or the medicare competency evaluation program for home health aides as specified in 42 C.F.R. 484.36 ( August 12, 2005), and

(ii) Obtain and maintain first aid certification from a class that is not solely internet-based and that includes hands-on training by a certified first aid instructor and a successful return demonstration of what was learned in the course.

(b) Maintain evidence of the completion of twelve hours of in-service continuing education within a twelve-month period, excluding agency and program-specific orientation. Continuing education must be initiated immediately , and must be completed annually thereafter.

(c) Receive supervision from an Ohio-licensed RN, or an Ohio-licensed LPN at the direction of an RN, in accordance with section 4723.01 of the Revised Code. The supervising RN, or LPN at the direction of an RN, must:

(i) Conduct a face-to-face consumer home visit explaining the expected activities of the personal care aide, and identifying the consumer's personal care aide services.

(ii) Conduct a face-to-face consumer home visit at least every sixty days while the personal care aide is present and providing care to evaluate the provision of personal care aide services, the consumer's satisfaction with care delivery, and personal care aide performance. The visit must be documented in the consumer's record.

(iii) Discuss the evaluation of personal care aide services with the case manager.

(d) Be able to read, write and understand English at a level that enables the provider to comply with all requirements set forth in the administrative rules governing the transitions carve-out waiver.

(e) Be able to effectively communicate with the consumer.

(7) Non-agency personal care aides must meet the following requirements:

(a) Before commencing service delivery personal care aides must have:

(i) Obtained a certificate of completion within the last twenty-four months for either a competency evaluation program or training and competency evaluation program approved or conducted by the Ohio department of health in accordance with section 3721.31 of the Revised Code; or the medicare competency evaluation program for home health aides as specified in 42 C.F.R. 484.36 ( August 12, 2005); or other equivalent training program. The program must include training in the following areas:

(a) Personal care aide services as defined in paragraph (B)(1) of this rule;

(b) Basic home safety; and

(c) Universal precautions for the prevention of disease transmission, including hand-washing and proper disposal of bodily waste and medical instruments that are sharp or may produce sharp pieces if broken.

(ii) Obtained and maintain first aid certification from a class that is not solely internet-based and that includes hands-on training by a certified first aid instructor and a successful return demonstration of what was learned in the course.

(b) Complete twelve hours of in-service continuing education annually that must occur on or before the anniversary date of their enrollment as a medicaid personal care aide provider. Continuing education topics include, but are not limited to consumer health and welfare, cardiopulmonary resuscitation (CPR), patient rights, emergency preparedness, communication skills, aging sensitivity, developmental stages, nutrition, transfer techniques, disease-specific trainings, and mental health issues.

(c) Comply with the consumer's or the consumer's authorized representative's specific personal care aide service instructions, and perform a return demonstration upon request of the consumer or the case manager.

(d) Comply with ODJFS monitoring requirements in accordance with rule 5101:3-45-06 of the Administrative Code.

(e) Be able to read, write and understand English at a level that enables the provider to comply with all requirements set forth in the administrative rules governing the transitions carve-out waiver.

(f) Be able to effectively communicate with the consumer.

(8) All personal care aide providers must maintain a clinical record for each consumer served. Medicare-certified, or otherwise-accredited agencies, must maintain the clinical records at their place of business in a manner that protects the confidentiality of these records. Non-agency personal care aides must maintain the clinical records at their place of business, and maintain a copy in the consumer's residence. For the purposes of this rule, the place of business must be a location other than the consumer's residence. At a minimum, the clinical record must contain the information listed in paragraphs (B)(8)(a) to (B)(8)(i) of this rule.

(a) Consumer identifying information, including but not limited to: name, address, age, date of birth, sex, race, marital status, significant phone numbers and health insurance identification numbers.

(b) Consumer medical history.

(d) A copy of the initial and all subsequent all services plans.

(e) Documentation of all drug and food interactions, allergies and dietary restrictions.

(f) A copy of any advance directives including, but not limited to, DNR order or medical power of attorney, if they exist.

(g) Documentation of tasks performed or not performed, arrival and departure times, and the dated signatures of the provider and consumer or authorized representative, verifying the service delivery upon completion of service delivery. Nothing shall prohibit the collection and maintenance of documentation through technology-based systems. The consumer's or authorized representative's signature of choice shall be documented on the consumer's all services plan, and shall include, but not be limited to, any of the following: a handwritten signature, initials, a stamp or mark, or an electronic signature.

(h) Progress notes signed and dated by the personal care aide, documenting all communications with the CM, treating physician, other members of the multidisciplinary team, and documenting any unusual events occurring during the visit, and the general condition of the consumer.

(i) A discharge summary, signed and dated by the departing non-agency personal care aide or the RN supervisor of an agency personal care aide, at the point the personal care aide is no longer going to provide services to the consumer, or when the consumer no longer needs personal care aide services. The summary should include documentation regarding progress made toward achievement of goals as specified on the consumer's all services plan and indicate any recommended follow-ups or referrals.

(1) "Adult day health center services (ADHCS)" are regularly scheduled services delivered at an adult day health center to consumers age eighteen or older. A qualifying adult day health center must be a freestanding building or a space within another building that shall not be used for other purposes during the provision of ADHCS.

(a) The services the adult day health center must provide are the following:

(i) Waiver nursing services as set forth in paragraph (A) of this rule, or personal care aide services as set forth in paragraph (B)(1) of this rule;

(ii) Recreational and educational activities; and

(iii) At least one meal, but no more than two meals, per day that meet the consumer's dietary requirements.

(b) The services the adult day health center may also make available include the following:

(i) Skilled therapy services as set forth in rule 5101:3-12-01 of the Administrative Code;

(ii) Transportation of the consumer to and from ADHCS.

(c) ADHCS are reimbursable at a full-day rate when five or more hours are provided to a consumer in a day. ADHCS are reimbursable at a half-day rate when less than five hours are provided to a consumer on a day.

(d) All of the services set forth in paragraphs (C)(1)(a) and (C)(1)(b) of this rule and delivered by an adult day health center shall not be reimbursed as separate services.

(2) ADHCS do not include services performed in excess of what is approved pursuant to, and specified on, the consumer's all services plan.

(3) In order to be a provider and submit a claim for reimbursement, providers of ADHCS must:

(a) Comply with all applicable rules set forth in Chapters 5101:3-45 and 5101:3-50 of the Administrative Code.

(b) Request reimbursement for the provision of services in accordance with rule 5101:3-50-06 of the Administrative Code.

(c) Be identified as the provider on the consumer's all services plan that is prior-approved by ODJFS or its designee, the number of hours for which the provider is authorized to furnish ADHCS to the consumer.

(d) Operate the adult day health center in compliance with all applicable federal, state and local laws, rules and regulations.

(4) All providers of ADHCS must:

(a) Comply with federal nondiscrimination regulations as set forth in 45 C.F.R. part 80 .

(b) Provide for replacement coverage of a consumer's loss due to theft, property damage, and/or personal injury; and maintain a written procedure identifying the steps a consumer takes to file a liability claim.Upon request, provide documentation to ODJFS or its designee verifying the coverage.

(c) Maintain evidence of non-licensed direct care staff's completion of twelve hours of in-service training within a twelve-month period, excluding agency and program-specific orientation, and must be completed annually thereafter.

(d) Assure that any waiver nursing services provided are within the nurse's scope of practice as set forth in paragraph (A)(1) of this rule.

(e) Provide task-based instruction to direct care staff providing personal care aide services as set forth in paragraph (B)(1) of this rule.

(f) Maintain, at all times, a paid direct care staff to consumer ratio of 1:6.

(5) Providers of ADHCS must maintain a clinical record for each consumer served in a manner that protects the confidentiality of these records. At a minimum, the clinical record must contain the information listed in paragraphs (C)(5)(a) to (C)(5)(i) of this rule.

(b) Consumer medical history.

(d) A copy of the initial and all subsequent all services plans.

(e) A copy of any advance directive including, but not limited to, DNR order or medical power of attorney, if they exist.

(f) Documentation of all drug and food interactions, allergies and dietary restrictions.

(g) Documentation that clearly shows the date of ADHCS delivery, including tasks performed or not performed, and the consumer's arrival and departure times. Nothing shall prohibit the use of technology-based systems in collecting and maintaining the documentation required by the paragraph.

(h) A discharge summary, signed and dated by the departing ADHCS provider, at the point the ADHCS provider is no longer going to provide services to the consumer, or when the consumer no longer needs ADHCS. The summary should include documentation regarding progress made toward goal achievement and indicate any recommended follow-ups or referrals.

(i) Documentation of the information set forth in paragraphs (A)(6)(e), (A)(6)(f), (A)(6)(i), (A)(6)(j) and (A)(6)(k) of this rule when the consumer is provided waiver nursing and/or skilled therapy services.

(D) Home delivered meal services.

(1) "Home delivered meal service" is defined as the provision of meals to a consumer who has a need for a home delivered meal based on a deficit in an ADL or a deficit in an IADL identified during the assessment process. The service includes the preparation, packaging and delivery of a safe and nutritious meal(s) to a consumer at his or her home. A consumer may be authorized to receive up to two home delivered meals per day.

(2) Home delivered meals:

(a) Shall be furnished in accordance with menus that are approved in writing by a licensed dietitian who is currently registered with the commission on dietetic registration.

(b) Shall take into consideration the consumer's medical restrictions, religious, cultural and ethnic background and dietary preferences.

(c) Shall be prepared by a provider who is in compliance with Chapters 918., 3715. and 3717. of the Revised Code and all applicable Administrative Code rules adopted thereunder. For the purposes of this rule, reheating a prepared home delivered meal is not the same as preparing a meal.

(d) Shall be individually packaged if it is a heated meal.

(e) May be individually packaged if it is an unheated, shelf-stable meal, or may have components separately packaged, so long as the components are clearly marked as components of a single meal.

(f) May include a therapeutic diet that requires a daily amount or distribution of one or more specified nutrients in order to treat a disease or clinical condition, or eliminate, decrease or increase certain substances in the consumer's diet. A therapeutic diet must be prescribed by a licensed physician or dietitian. A new order must be documented in the consumer's clinical record every ninety days.

(3) Home delivered meals shall not:

(a) Include services or activities performed in excess of what is approved on the consumer's all services plan.

(b) Supplement or replace meal preparation activities that occur during the provision of waiver nursing, personal care aide, adult day health center, home care attendant or any other similar services.

(d) Include bulk ingredients, liquids and other food used to prepare meals independently or with assistance. Bulk ingredients and liquids include, but are not limited to: food that must be portioned out and prepared, or any food that must be cooked or prepared.

(e) Be prepared while the consumer is hospitalized or is residing in an institutional setting.

(4) In order to be a provider and to submit a claim for reimbursement, all home delivered meal providers must meet all of the following requirements:

(a) Comply with all applicable rules set forth in Chapters 5101:3-45 and 5101:3-50 of the Administrative Code.

(b) Request reimbursement for the provision of home delivered meal services in accordance with rule 5101:3-50-06 of the Administrative Code.

(c) Be identified as the home delivered meal provider, and be specified, on the consumer's all services plan that is prior-approved by the department or its designee.

(d) Possess any applicable current, valid license or certificate from the local health department, and retain records of all reports related to the licensure or certification.

(e) Assure that all meals are provided as identified on the consumer's all services plan.

(f) Submit claims that do not exceed two meals per day per consumer.

(g) Maintain documentation as set forth in paragraph (D)(8) of this rule.

(5) Home delivered meal service providers shall assure all meals, with the exception of a therapeutic diet prescribed and prepared in accordance with paragraph (D)(2)(f) of this rule, meet the following requirements with regard to nutritional adequacy:

(a) Meet one-third of the current dietary reference intakes (DRI) established by the food and nutrition board of the institute of medicine of the national academy of sciences.

(b) Follow the current dietary guidelines for Americans as published by the U.S. department of agriculture.

(6) Home delivered meal service providers shall assure the safe delivery of meals as authorized by the department or its designee on the consumer's all services plan.

(a) Ready-to-eat, temperature-controlled meals must be labeled with a preparation date. The date shall include the month, day and year the meals were prepared, and shall list, immediately adjacent to this date, the phrase "packing" or "pack date." All other meals shall be labeled with the month, day and year by which the meal shall be consumed or discarded, and shall list the date immediately following the phrase "sell by" or "use before."

(b) The provider must document evidence of a time and temperature monitoring system for food preparation, handling and delivery.

(d) When using a thermostatically-controlled meal delivery vehicle, the provider must maintain verification of testing meal temperatures no less than monthly. When using other meal delivery vehicles, the provider must maintain verification of testing meal temperatures no less than weekly.

(e) The provider must establish with the consumer, and document in the consumer's record, a routine date and time for meal delivery. The provider must notify the consumer if delivery of the meal(s) will be delayed more than one hour past established time.

(f) The provider must furnish written delivery instructions to the driver.

(g) The provider must furnish the consumer or authorized representative with clear instruction on how to safely heat or reheat each meal.

(7) Home delivered meal service providers shall assure the following with regard to training and continuing education:

(a) All personnel who participate in food preparation, food handling and/or delivery, including volunteers, must:

(i) Receive training and orientation on the following as relevant with the individual's job duties:

(a)Sensitivity to the needs of older adults and people with physical disabilities or cognitive impairments;

(b)Handling emergencies;

(c)Food storage, preparation and handling;

(d)Food safety and sanitation;

(e)Meal delivery; and

(f)Handling hazardous materials.

(ii) Successfully complete four hours of continuing education each year on the topics relevant to the individual's job duties.

(b) The provider must develop a training plan and conduct and document annual training and continuing education activities.

(8) At a minimum, home delivered meal service providers must maintain and make available, upon request, the following:

(a) A record for each consumer served that contains a copy of the initial and all subsequent all services plans, all dietary orders and instructions prepared by the physician, menus approved by the dietitian, and any additional information supporting meal delivery as specified on the all services plan.

(b) Documentation that each meal complies with paragraphs (D)(5)(a) and (D)(5)(b) of this rule.

(d) Documentation from the provider that the consumer or authorized representative has been furnished with clear instructions about how to safely heat or reheat each meal.

(e) Documentation that verifies delivery of home delivered meals as authorized on the consumer's all services plan. Documentation shall include, but not be limited to, the consumer's name, the dated signature of the home delivered meal service provider, the established delivery date and time, the actual time of delivery of all meals and the number of meals delivered, signature or initials of the person delivering the meal(s) and the signature or initials of the consumer or authorized representative receiving the meal(s). Nothing shall prohibit the collection or maintenance of documentation through technology-based systems. The consumer's or authorized representative's signature of choice shall be documented on the consumer's all services plan, and shall include, but not be limited to, any of the following: a handwritten signature, initials, a stamp or mark, or an electronic signature.

(f) Documentation that the home delivered meal delivery staff possesses a current and valid driver's license.

(g) Documentation of vehicle owner's liability insurance.

(h) Documentation that the provider has established a routine delivery time with the consumer.

(i) All local health department inspection reports and documented findings, any resulting plans of correction, and any follow-up reports.

(j) All Ohio department of agriculture inspection reports and documented findings, any resulting plans of correction and any follow-up reports.

(k) All U.S. department of agriculture inspection reports and documented findings, any resulting plans of correction, and any follow-up reports.

(l) All licensure/certification documents required as a result of paragraph (D)(4)(e) of this rule.

(9) Home delivered meal provider inspections and follow-up.

(a) Home delivered meal service providers cited for critical violations, as that term "critical violations" is used in paragraph (B) of rule 3717-1-02.4 of the Administrative Code, during their local health department inspections, shall notify ODJFS or its designee no more than forty-eight hours after issuance of the citation. The provider shall, within forty-eight hours, send to ODJFS or its designee a copy of the inspection report, any plans of correction and any follow-up reports.

(b) Home delivered meal service providers inspected by the Ohio department of agriculture division of food safety and placed on priority status or notice status shall notify ODJFS or its designee no more than two business days after the issuance of the report of priority status, or after the issuance of the report of notice status in accordance with section 913.42 of the Revised Code. The provider shall, within five business days, send to ODJFS or its designee, a copy of the report(s) with documented findings, any notices issued by the Ohio department of agriculture, and any resulting plans of correction and follow-up reports.

(c) Home delivered meal service providers inspected by the Ohio department of agriculture division of meat inspection or the U.S. department of agriculture food safety inspection service shall notify ODJFS or its designee no more than two business days after it takes a withholding action against, or it suspends the provider in accordance with 9 C.F.R. 500.3 (November 29, 1999) and/or 9 C.F.R. 500.4 (November 29, 1999). The provider shall, within five business days, send to ODJFS or its designee, a copy of the action issued by the Ohio department of agriculture or the U.S. department of agriculture food safety inspection service, any resulting plans of correction and any follow-up reports.

(d) ODJFS may immediately suspend and terminate a provider's authorization to furnish home delivered meal services pursuant to section 5111.6 of the Revised Code and rule 5101:3-1-17.6 of the Administrative Code if ODJFS or its designee receives credible information that the provider poses a significant threat to the health and welfare of one or more consumers due to noncompliance with one or more of the requirements set forth in this rule.

(E) Home modification services.

(1) "Home modification services" are environmental accessibility adaptations to structural elements of the interior or exterior of a consumer's home that enable the consumer to function with greater independence in the home and remain in the community. Home modification services are not otherwise available through any other funding source and must be suitable to enable the consumer to function with greater independence, avoid institutionalization and reduce the need for human assistance. They shall not exceed a total of ten thousand dollars within a twelve-month calendar year per consumer. ODJFS or its designee shall only approve the lowest cost alternative that meets the consumer's needs as determined during the assessment process.

(a) The property owner must give written consent for the home modification that indicates an understanding that the transitions carve-out waiver will not pay to have the property returned to its prior condition.

(b) The need for home modification services must be identified

by an occupational therapist or physical therapist as licensed pursuant to sections 4755.08 and 4755.44 of the Revised Code, during an in-person evaluation of the site to be modified, and with the consumer present.

(c) Home modifications include repairs of previous home modifications excluding those described in paragraph (E)(2)(e) of this rule.

(2) Home modification services do not include:

(a) Changes to a home that are of general utility and are not directly related to the environmental accessibility needs of the consumer (i.e., carpeting, roof repair, central air conditioning, etc.) .

(b) Adaptations that add to the total square footage of the home .

(d) The same type of home modification for the same consumer during the same twelve-month calendar year, unless there is a documented need for the home modification or a documented change in the consumer's medical and/or physical condition that requires the replacement.

(e) New home modifications or repair .of previously approved home modifications that have been damaged as a result of confirmed misuse, abuse or negligence.

(3) Home modification service providers shall be reimbursed for the actual cost of material and/or labor for the home modification as identified in the bid specification. The reimbursement may only be adjusted if the job specifications are modified in writing by ODJFS or its designee and the adjustment is warranted. Family members and volunteers shall meet all of the provider requirements set forth in paragraph (E) of this rule, however, they shall only be reimbursed for the cost of materials.

(4) In order to be a provider and submit a claim for reimbursement, providers of home modification services must:

(a) Comply with all applicable rules set forth in Chapters 5101:3-45 and 5101:3-50 of the Administrative Code.

(b) Request reimbursement for the provision of services in accordance with rule 5101:3-50-06 of the Administrative Code.

(c) Be identified as the provider, and have specified, on the consumer's all services plan that is prior-approved by ODJFS or its designee, the home modification services that the provider is authorized to furnish to the consumer.

(d) Provide documentation that the home modification was completed in accordance with the agreed upon specifications using all of the materials and equipment cited in the bid .

(e) Provide documentation that the home modification was tested and in proper working order .

(f) Provide documentation that the home modification met all applicable state and local building codes .

(g) Provide documentation that the home modification meets the consumer's needs and complies with the Americans with Disabilities Act (ADA) (September 25, 2008), the Uniform Federal Accessibility Standards (UFAS) (January 18, 1991) or the Fair Housing Act (FHA) (April 11, 1968), as applicable. If a home modification must be customized in order to meet the consumer's needs, and that customization will not be compliant with the ADA, UFAS or FHA, it must be prior-approved by ODJFS or its designee, in consultation with the consumer and/or authorized representative and the consumer's interdisciplinary team.

(h) Maintain licensure, insurance and bonding for general contracting services of applicable jurisdictions and provide proof to ODJFS or its designee upon request. Family members and volunteers are exempt from this requirement when they deliver home modification services to the consumer .

(i) Obtain a final written approval from the consumer and ODJFS or its designee after completion of the home modification service.

(5) Selection of home modification service providers.

(a) In consultation with the consumer, authorized representative and/or caregiver(s), ODJFS or its designee shall develop job specifications based on the in-person evaluation required in paragraph (E)(1)(b) of this rule to meet the consumer's environmental accessibility needs with the lowest cost alternative.

(b) At a minimum, ODJFS or its designee shall send the home modification specifications to every known home modification service provider in the consumer's county of residence and all contiguous counties, and shall invite the submission of competitive bids. Home modification providers shall submit bids that include all of the following:

(i) A drawing or diagram of the home modification;

(ii) An itemized list of all materials needed for the home modification;

(iii) An itemized list of the cost of the materials needed for the home modification;

(iv) An itemized list of the labor costs;

(v) A written statement of all warranties provided including, at a minimum, a minimum one-year warranty for all materials and workmanship associated with the home modification; and

(vi) A written attestation that the provider, all employees and/or all subcontractors to be used to perform the job specifications have the necessary experience and skills, and meet all of the provider requirements set forth in Chapters 5101:3-45 and 5101:3-50 of the Administrative Code.

(c) ODJFS or its designee shall review all submitted bids and the home modification service will be awarded to the lowest responsive and most responsible bidder, with price and other relevant factors being considered in the selection process.

(F) Supplemental adaptive and assistive device services.

(1) "Supplemental adaptive and assistive device services" are medical equipment, supplies and devices, and vehicle modifications to a vehicle owned by the consumer, or a family member, or someone who resides in the same household as the consumer, that are not otherwise available through any other funding source and that are suitable to enable the consumer to function with greater independence, avoid institutionalization, and reduce the need for human assistance. All supplemental adaptive and assistive device services shall be prior-approved by ODJFS or its designee. ODJFS or its designee shall only approve the lowest cost alternative that meets the consumer's needs as determined during the assessment process.

(a) Reimbursement for medical equipment, supplies and vehicle modifications shall not exceed a combined total of ten thousand dollars within a calendar year per consumer.

(b) ODJFS or its designee shall not approve the same type of medical equipment, supplies and devices for the same consumer during the same calendar year, unless there is a documented need for ongoing medical equipment, or a documented change in the consumer's medical and/or physical condition requiring the replacement.

(c) ODJFS or its designee shall not approve the same type of vehicle modification for the same consumer within the same three-year period, unless there is a documented change in the consumer's medical and/or physical condition requiring the replacement.

(d) Supplemental adaptive and assistive device services do not include:

(i) Items considered by the federal food and drug administration as experimental or investigational;

(ii) Funding of downpayments toward the purchase or lease of any supplemental adaptive and assistive device services;

(iii) Equipment, supplies or services furnished in excess of what is approved pursuant to, and as specified on the consumer's all services plan;

(iv) New equipment or supplies or repair of previously approved equipment or supplies that have been damaged as a result of confirmed misuse, abuse or negligence; and

(v) Activities described in paragraph (F)(2)(c) of this rule.

(2) Vehicle modifications.

(a) Reimbursable vehicle modifications include operating aids, raised and lowered floors, raised doors, raised roofs, wheelchair tie-downs, scooter/wheelchair handling devices, transfer seats, remote devices, lifts, equipment repairs and/or replacements, and transfers of equipment from one vehicle to another for use by the same consumer. Vehicle modifications may also include the itemized cost, and separate invoicing of vehicle adaptations associated with the purchase of a vehicle that has not been pre-owned or pre-leased.

(b) Before the authorization of a vehicle modification, the consumer and, if applicable, any other person(s) who will operate the vehicle must provide the ODJFS or its designee with documentation of:

(i) A valid driver's license, with appropriate restrictions, and if requested, evidence of the successful completion of driver training from a qualified driver rehabilitation specialist, or a written statement from a qualified driver rehabilitation specialist attesting to the driving ability and competency of the consumer and/or other person(s) operating the vehicle;

(ii) Proof of ownership of the vehicle to be modified;

(iii) Vehicle owner's collision and liability insurance for the vehicle being modified; and

(iv) A written statement from a certified mechanic stating the vehicle is in good operating condition.

(i) Payment toward the purchase or lease of a vehicle, except as set forth in paragraph (F)(2)(a) of this rule;

(ii) Routine care and maintenance of vehicle modifications and devices;

(iii) Permanent modification of leased vehicles;

(iv) Vehicle inspection costs;

(v) Vehicle insurance costs;

(vi) New vehicle modifications or repair of previously approved modifications that have been damaged as a result of confirmed misuse, abuse or negligence; and

(vii) Services performed in excess of what is approved pursuant to, and specified on, the consumer's all services plan.

(3) In order to be a provider and submit a claim for supplemental adaptive and assistive device services, the provider must:

(a) Comply with all applicable rules set forth in Chapters 5101:3-45 and 5101:3-50 of the Administrative Code.

(b) Request reimbursement for the provision of services in accordance with rule 5101:3-50-06 of the Administrative Code.

(c) Be identified as the provider, and have specified, on the consumer's all services plan that is prior-approved by ODJFS or its designee, the supplemental adaptive and assistive device services the provider is authorized to furnish to the consumer.

(d) Assure that all manufacturer's rebates have been deducted before requesting reimbursement for supplemental adaptive and assistive device services .

(e) Assure that the supplemental adaptive and assistive device was tested and is in proper working order, and is subject to warranty in accordance with industry standards.

(4) Providers of supplemental adaptive and assistive device services must maintain a clinical record for each consumer served in a manner that protects the confidentiality of these records. At a minimum, the clinical record must contain the information listed in paragraphs (F)(4)(a) to (F)(4)(d) of this rule.

(a) Consumer identifying information, including but not limited to name, address, age, date of birth, sex, race, marital status, significant phone numbers, and health insurance identification numbers.

(b) Name of consumer's treating physician.

(d) Documentation that clearly shows the date the supplemental adaptive and assistive device service was provided. Nothing shall prohibit the use of technology-based systems in collecting and maintaining the documentation required by this paragraph.

(G) Out-of-home respite services.

(1) "Out-of-home respite services" are services delivered to a consumer in an out-of-home setting in order to allow respite for caregivers normally providing care. The service must include an overnight stay.

(a) The services the out-of-home respite provider must make available are:

(i) Waiver nursing services as set forth in paragraph (A) of this rule;

(ii) Personal care aide services as set forth in paragraph (B)(1) of this rule; and

(iii) Three meals per day that meet the consumer's dietary requirements.

(b) All services set forth in paragraph (G)(1)(a) of this rule and delivered during the provision of out-of-home respite services shall not be reimbursed as separate services.

(2) Out-of-home respite services do not include services performed in excess of what is approved pursuant to, and specified on, the consumer's all services plan.

(3) In order to be a provider and submit a claim for reimbursement, providers of out-of-home respite services must:

(a) Comply with all applicable rules set forth in Chapters 5101:3-45 and 5101:3-50 of the Administrative Code.

(b) Request reimbursement for the provision of services in accordance with rule 5101:3-50-06 of the Administrative Code.

(c) Be identified as the provider, and have specified, on the consumer's all services plan that is prior-approved by ODJFS or its designee, the number of hours for which the provider is authorized to furnish out-of-home respite services to the consumer.

(d) Be either:

(i) An intermediate care facility for the mentally retarded and developmentally disabled (ICF-MR) licensed and certified in accordance with rules 5101:3-3-02 and 5101:3-3-02.3 of the Administrative Code; or

(ii) A nursing facility (NF) licensed and certified in accordance with rules 5101:3-3-02 and 5101:3-3-02.3 of the Administrative Code; or

(iii) Another licensed setting approved by ODJFS or its designee.

(e) Be providing out-of-home respite services for one individual, or for up to three individuals in a group setting on the same date.

(4) All providers of out-of-home respite services must:

(a) Comply with federal nondiscrimination regulations as set forth in 45 C.F.R. part 80 .

(b) Provide for coverage of a consumer's loss due to theft, property damage, and/or personal injury; and maintain a written procedure identifying the steps a consumer takes to file a liability claim. Upon request, provide documentation to ODJFS or its designee verifying the coverage.

(c) Maintain evidence of non-licensed direct care staff's completion of eight hours of in-service training within a twelve-month period, excluding agency and program-specific orientation. In-service training must be initiated immediately after the non-licensed direct care staff's first anniversary of employment with the provider, and must be completed annually thereafter.

(d) Assure that any waiver nursing services provided are within the nurse's scope of practice as set forth in paragraph (A)(1) of this rule.

(e) Provide task-based instruction to direct care staff providing personal care aide services as defined in paragraph (B)(1) of this rule.

(5) Providers of out-of-home respite services must maintain a clinical record for each consumer served in a manner that protects the confidentiality of these records. The clinical record must contain the information listed in paragraphs (G)(5)(a) to (G)(5)(i) of this rule.

(a) Consumer's identifying information, including but not limited to name, address, age, date of birth, sex, race, marital status, significant phone numbers and health insurance identification numbers.

(b) Consumer medical history.

(d) A copy of the initial and all subsequent all services plans.

(e) A copy of any advance directives including, but not limited to, DNR order or medical power of attorney, if they exist.

(f) Documentation of all drug and food interactions, allergies and dietary restrictions.

(g) Documentation that clearly shows the date of out-of-home respite service delivery, including tasks performed or not performed. Nothing shall prohibit the use of technology-based systems in collecting and maintaining the documentation required by this paragraph.

(h) A discharge summary, signed and dated by the departing out-of-home respite service provider, at the point the service provider is no longer going to provide services to the consumer, or when the consumer no longer needs out-of-home respite services.

(i) Documentation of the information set forth in paragraphs (A)(6)(e), (A)(6)(f), (A)(6)(i), (A)(6)(j) and (A)(6)(k) of this rule when the consumer is provided waiver nursing.

(H) Emergency response services.

(1) "Emergency response services (ERS)" are emergency intervention services composed of telecommunications equipment (ERS equipment), an emergency response center and a medium for two-way, hands-free communication between the consumer and the emergency response center. Personnel at the emergency response center intervene in an emergency when the center receives an alarm signal from the ERS equipment.

(2) ERS equipment shall include a variety of remote or other specialty activation devices from which the consumer can choose in accordance with the consumer's specific needs. All ERS equipment shall have an internal battery that provides at least twenty-four hours of power without recharging and sends notification to the emergency response center when the battery's level is low. Equipment includes, but is not limited to:

(a) Wearable waterproof activation devices;

(b) Devices that offer:

(i) Voice-to-voice communication capability,

(ii) Visual indication of an alarm that may be appropriate if the consumer is hearing impaired, or

(iii) Audible indication of an alarm that may be appropriate if the consumer is visually impaired.

(3) ERS does not include the following:

(a) Equipment such as a boundary alarm, a medication dispenser, a medication reminder, or any other equipment or home medical equipment or supplies, regardless of whether such equipment is connected to the ERS equipment.

(b) In-home communication connection systems used to supplant routine supervision of consumers under the age of eighteen.

(d) Services performed in excess of what is approved pursuant to a consumer's all services plan.

(e) New equipment or repair of previously approved equipment that has been damaged as a result of confirmed misuse, abuse or negligence.

(4) In order to be a provider and submit a claim for ERS, the provider must:

(a) Comply with all applicable rules set forth in Chapters 5101:3-45 and 5101:3-50 of the Administrative Code.

(b) Request reimbursement for the provision of services in accordance with rule 5101:3-50-06 of the Administrative Code.

(c) Be identified as the provider, and have specified on the consumer's all services plan, the ERS that the provider is authorized to furnish.

(5) ERS requirements.

(a) Providers shall assure that all consumers are able to choose the ERS equipment that meets their specific needs as set forth on their all services plan.

(b) Providers shall furnish each ERS consumer with an initial face-to-face demonstration and training on how to use their ERS equipment. Additional training shall be provided to designated responders as part of the monthly service in accordance with paragraph (H)(5)(c) of this rule, and to the consumer, caregiver and ODJFS or its designee upon request.

(c) Before, or during the delivery of ERS equipment, the provider shall work with the consumer and/or the consumer's authorized representative, and the consumer's case manager to develop a written response plan regarding how to proceed in the event the ERS signals an alarm. The written response plan shall be updated as often as desired by the consumer and/or the consumer's authorized representative, but shall be reviewed no less than every six months.

(i) The written response plan shall include a summary of the consumer's health history and functioning level, as well as the name of, and contact information for, at least one individual who will serve as the consumer's designated responder. If the consumer identifies more than one designated responder, the consumer shall also indicate the order in which the responders should be contacted. For the purposes of this rule, "designated responder" means an individual or individuals who the consumer and/or authorized representative chooses to be contacted by the ERS provider in the event the ERS signals an alarm. If fewer than two individuals are designated as responders, then emergency service personnel shall be designated as responders in the plan.

(ii) The provider shall furnish initial training to all designated responders before activation of the consumer's ERS equipment, and on an annual basis. At a minimum, the training shall include:

(a)Instruction regarding how to respond to an emergency, including how to contact emergency service personnel; and(b)Distribution of written materials regarding how to respond to an ERS signal.

(iii) The provider shall work with the consumer and/or the consumer's authorized representative, and the case manager to revise the written response plan when there is a change in designated responders.

(a) If the consumer has only one designated responder, the provider shall secure a replacement within four days after notification of the change, and document this change in the plan.

(b)If the consumer has two or more designated responders, the provider shall secure a replacement responder within seven days after notification of the change, and document this change in the plan.

(c)If the provider is unable to secure a replacement responder within the required time period, then the provider shall notify the case manager, and emergency service personnel shall be designated as the responder in the plan.

(iv) In the event a consumer sends a signal but a designated responder cannot be reached, the provider shall contact emergency service personnel and shall remain on the line until emergency service personnel arrive on the scene of the emergency.

(d) Providers shall assure that emergency response centers:

(i) Employ and train staff to receive and respond to signals from consumers twenty-four hours per day, three hundred sixty-five days per year.

(ii) Maintain the capacity to respond to all alarm signals.

(iii) Maintain a secondary capacity to respond to all incoming signals in case the primary system is unable to respond to alarm signals.

(iv) Respond to each alarm signal within sixty seconds of receipt.

(v) Notify ODJFS or its designee of all emergencies involving a consumer within twenty-four hours.

(vi) Conduct monthly testing of ERS equipment to assure proper operation.

(vii) Replace, within twenty-four hours of notification and at no cost to the consumer, or ODJFS or its designee, malfunctioning ERS equipment that has not been damaged as a result of confirmed misuse, abuse or negligence.

(viii) Replace, at no cost to the consumer, or ODJFS or its designee, no more than one ERS pendant per year.

(ix) Operate all ERS communication lines free of charge.

(6) At a minimum, providers of ERS must maintain the documentation set forth in paragraphs (H)(6)(a) to (H)(6)(h) of this rule. Nothing shall prohibit the use of technology-based systems in collecting and maintaining the documentation required by this paragraph.

(a) A log containing the name and contact information of each consumer, and his or her authorized representative.

(b) A copy of each consumer's all services plan.

(c) All records necessary and in such form so as to fully disclose the extent of ERS provided and significant business transactions pursuant to rule 5101:3-1-17.2 of the Administrative Code.

(d) Documentation of all consumer, designated responder and ERS provider training that is required pursuant to paragraph (H)(5) of this rule.

(e) A written record of the date of delivery and installation of the ERS equipment, with the consumer's or authorized representative's signature verifying delivery and installation. The consumer's or authorized representative's signature of choice shall be documented on the all services plan and shall include, but not be limited to, any of the following: a handwritten signature, initials, a stamp or mark, or an electronic signature.

(f) A written record of the monthly testing conducted on each consumer's ERS equipment, including date, time and results of the test.

(g) A record of each service-related consumer contact including, but not limited to, the date and time of the contact, a summary of the incident, the service delivered (including the service of responding to a false alarm), and the name of each person having contact with the consumer.

(h) A copy of the consumer's written response plan as set forth in paragraph (H)(5)(c) of this rule.

(I) Supplemental transportation services.

(1) "Supplemental transportation services" are transportation services that are not available through any other resource that enable a consumer to access waiver services and other community resources specified on the consumer's all services plan. Supplemental transportation services include, but are not limited to assistance in transferring the consumer from the point of pick-up to the vehicle and from the vehicle to the destination point.

(2) Supplemental transportation services do not include services performed in excess of what is approved pursuant to, and specified on, the consumer's all services plan.

(3) In order to be a provider and submit a claim for supplemental transportation services, the provider must:

(a) Comply with all applicable rules set forth in Chapters 5101:3-45 and 5101:3-50 of the Administrative Code.

(b) Request reimbursement for the provision of services in accordance with rule 5101:3-50-06 of the Administrative Code.

(c) Be identified as the provider, and have specified on, the consumer's all services plan that is prior-approved by ODJFS or its designee, the amount of supplemental transportation services the provider is authorized to furnish to the consumer.

(4) Agency supplemental transportation service providers must:

(a) Maintain a current list of drivers.

(b) Maintain documentation that all drivers providing supplemental transportation services are age eighteen or older.

(d) Maintain collision and liability insurance for each vehicle and driver used to provide supplemental transportation services.

(e) Obtain and exhibit evidence of a valid motor vehicle inspection from the Ohio highway patrol for each vehicle used in the provision of supplemental transportation services.

(f) Obtain and maintain a certificate of completion of a course in first aid for each driver used to provide supplemental transportation services that:

(i) Is not provided solely through the internet;

(ii) Includes hands-on training provided by a certified first aid instructor; and

(iii) Requires the individual to perform a successful return demonstration of what was learned in the course.

(g) Assure that drivers are not the consumer's legally responsible family member as that term is defined in rule 5101:3-45-01 of the Administrative Code.

(h) Assure that drivers are not the consumer's foster caregivers.

(5) Non-agency supplemental transportation service providers must:

(a) Be age eighteen or older.

(b) Possess a valid driver's license.

(d) Obtain and exhibit evidence of a valid motor vehicle inspection from the Ohio highway patrol for each vehicle used in the provision of supplemental transportation services.

(e) Obtain and maintain a certificate of completion of a course in first aid that:

(i) Is not provided solely through the internet;

(ii) Includes hands-on training provided by a certified first aid instructor;

(iii) Requires the individual to perform a successful return demonstration of what was learned in the course.

(f) Not be the consumer's legally responsible family member as that term is defined in rule 5101:3-45-01 of the Administrative Code.

(g) Not be the consumer's foster caregiver.

(6) All supplemental transportation service providers must maintain documentation that, at a minimum, includes a log identifying the consumer transported, the date of the service, pick-up point, destination point, mileage for each trip, and the signature of the consumer receiving supplemental transportation services, or the consumer's authorized representative. The consumer's or authorized representative's signature of choice shall be documented on the consumer's all services plan and shall include, but not be limited to any of the following: a handwritten signature, initials, a stamp or mark, or an electronic signature.

Effective: 10/25/2010
R.C. 119.032 review dates: 08/10/2010 and 10/01/2015
Promulgated Under: 119.03
Statutory Authority: 5111.85
Rule Amplifies: 5111.01 , 5111.02 , 5111.85 , 5111.856
Prior Effective Dates: 3/30/90 (Emer), 6/29/90, 7/1/90, 3/12/92 (Emer), 6/1/92, 7/31/92 (Emer), 10/30/92, 7/1/93 (Emer), 7/30/93, 9/1/93, 1/1/96, 7/1/98, 7/1/06

5160-50-04.1 Transitions carve-out waiver program: home care attendant services.

The requirements set forth in this rule begin when the Ohio department of job and family services (ODJFS) receives approval from the centers of medicare and medicaid services (CMS) of an amendment adding home care attendant services to the transitions carve-out waiver, or on the effective date of this rule, whichever is later.

(A) The following definitions are applicable to this rule:

(1) "Adult" means an individual at least eighteen years of age.

(2) "Authorized representative" means the following:

(a) In the case of a consumer who is a minor, the consumer's parent, custodian, or guardian. The authorized representative shall be present and awake during the delivery of home care attendant services.

(b) In the case of a consumer who is an adult, an individual selected by the consumer to act on the consumer's behalf for the purposes regarding home care attendant services. The authorized representative shall be present and awake during the delivery of home care attendant services.

(3) "Authorizing health care professional" means a health care professional who, pursuant to section 5111.887 of the Revised Code, authorizes a home care attendant to assist a consumer with self-administration of medication, nursing tasks, or both. The consumer, authorized representative, legally responsible family member, legal guardian, and foster caregiver are prohibited from being the authorizing health care professional.

(4) "Consumer" means an individual to whom all of the following apply:

(a) The individual is enrolled in the transitions carve-out waiver.

(b) The individual has a medically determinable physical impairment to which both of the following apply:

(i) It is expected to last for a continuous period of not less than twelve months.

(ii) It causes the individual to require assistance with activities of daily living, self-care, and mobility, including either assistance with self-administration of medication or the performance of nursing tasks, or both.

(c) In the case of an individual who is an adult, the individual is mentally alert and is, or has an authorized representative who is, capable of freely choosing home care attendant service providers in accordance with rule 5101:3-45-03 of the Administrative Code, and selecting, directing the actions of, and dismissing a home care attendant.

(i) In accordance with section 5111.8810 of the Revised Code, a consumer who is an adult may select an authorized representative by submitting a written notice of the consumer's selection to the director of ODJFS. The notice shall specifically identify the individual the consumer selects as authorized representative and may limit what the authorized representative may do on the consumer's behalf regarding home care attendant services.

(ii) A consumer may not select the consumer's home care attendant to be the consumer's authorized representative.

(d) In the case of an individual who is a minor, the individual has an authorized representative who is capable of freely choosing home care attendant service providers in accordance with rule 5101:3-45-03 of the Administrative Code, and selecting, directing the actions of, and dismissing a home care attendant.

(5) "Controlled substance" has the same meaning as in section 3719.01 of the Revised Code.

(6) "Custodian" has the same meaning as in section 2151.011 of the Revised Code.

(7) "Gastrostomy tube" means a percutaneously inserted catheter that terminates in the stomach.

(8) "Group setting" means a situation in which a home care attendant service provider furnishes home care attendant services in accordance with this rule, and as authorized by ODJFS, to two or three individuals who reside at the same address.

(9) "Guardian" has the same meaning as in section 2111.01 of the Revised Code.

(10) "Health care professional" means a physician or registered nurse who holds a current, valid, unrestricted license.

(11) "Home care attendant" means an individual holding a valid medicaid provider agreement in accordance with section 5111.881 of the Revised Code and paragraph (E)(2) of this rule that authorizes the individual to provide home care attendant services to a consumer.

(12) "Jejunostomy tube" means a percutaneously inserted catheter that terminates in the jejunum.

(13) "Medication" means a drug as defined in section 4729.01 of the Revised Code.

(14) "Minor" means an individual under eighteen years of age.

(15) "Nursing tasks" means skilled tasks that would otherwise be performed by a registered nurse (RN), or a licensed practical nurse (LPN) at the direction of an RN.

(16) "Oral medication" means any medication that can be administered through the mouth, or through a gastrostomy tube or jejunostomy tube if through a pre-programmed pump or through a syringe. Oral medication may include medication administered through a metered dose inhaler.

(17) "Physician" means an individual authorized under Chapter 4731. of the Revised Code to practice medicine and surgery or osteopathic medicine and surgery.

(18) "Practice of nursing as a registered nurse," "practice of nursing as a licensed practical nurse (LPN)," and "registered nurse (RN)" have the same meanings as in section 4723.01 of the Revised Code. "Registered nurse" includes an advanced practice nurse as defined in section 4723.01 of the Revised Code.

(19) "Schedule II," schedule III," "schedule IV," and "schedule V" have the same meaning as in section 3719.01 of the Revised Code.

(20) "Topical medication" means any medication that is applied to the outer skin, including transdermal medications and eye, ear, and nose drops. Topical medication may also include vaginal or rectal suppositories.

(B) Home care attendant services are services provided to a consumer enrolled on the transitions carve-out waiver by an unlicensed non-agency provider in accordance with this rule. Home care attendant services include, but are not limited to, tasks that would otherwise be performed by an RN or an LPN at the direction of an RN. Home care attendant services include:

(1) Assistance with self-administration of medications as set forth in paragraph (C) of this rule.

(2) Assistance with the performance of nursing tasks as set forth in paragraph (D) of this rule.

(3) Personal care aide tasks as described in paragraph (B)(1) of rule 5101:3-50-04 of the Administrative Code when performed during a home care attendant service visit. Personal care aide tasks are not reimbursable separately as personal care aide services when they are performed during a home care attendant service visit.

(1) A home care attendant shall assist a consumer with the self-administration of only the following medication:

(a) Oral medications;

(b) Topical medications;

(d) Programming of a pump only used to deliver a routine dose of insulin;

(e) Medication administered via stable, labeled gastrostomy or jejunostomy tubes using pre-programmed pumps; and (f) Doses of schedule II, schedule III, schedule IV, and schedule V drugs only when administered orally or topically.

(2) Medication shall be maintained in its original container and the attached label shall match the dosage and means of administration set forth on the JFS 2389 "Home Care Attendant Medication Authorization Form" (7/10). The label on the container shall display all of the following:

(a) The consumer's full name in print;

(b) A dispensing date within the prior twelve months; and (c) The exact dosage and means of administration.

(3) Schedule II, schedule III, schedule IV, and schedule V drugs shall meet all of the following additional requirements:

(a) The medication(s) has a warning label on the bottle.

(b) The home care attendant shall count the medication(s) in the consumer's or authorized representative's presence and record the count on a log located in the consumer's clinical record.

(c) The medication(s) is recounted by the home care attendant in the consumer's or authorized representative's presence at least monthly, and the count is reconciled on a log located in the consumer's clinical record. The home care attendant shall notify the authorizing health care professional, in writing, within twenty-four hours if:

(i) The medication(s) is missing; and

(ii) The count of medication(s) cannot be reconciled.

(d) The medication(s) is stored separately from all other medications, and is secured and locked at all times when not being administered to the consumer in order to prevent access by unauthorized individuals.

(D) Assistance with the performance of nursing tasks.

(1) A home care attendant may provide assistance with the performance of nursing tasks that are not expressly excluded in accordance with paragraph (D)(2) of this rule.

(2) A home care attendant shall not assist a consumer with the performance of any of the following nursing tasks:

(a) Intravenous (IV) insertion, removal, or discontinuation;

(b) Intramuscular injections;

(d) Subcutaneous injections, except for routine doses of insulin pursuant to paragraph (C)(1)(c) of this rule;

(e) Programming of a pump used to deliver medications (including but not limited to epidural, subcutaneous, and IV), except for routine doses of insulin pursuant to paragraph (C)(1)(d) of this rule;

(f) Insertion or initiation of infusion therapies; and

(g) Central line dressing changes.

(3) Performance of nursing tasks shall be summarized and submitted on the JFS 02390 "Home Care Attendant Skilled Task Authorization Form" (7/10).

(E) In order to provide services and to submit a claim for reimbursement, home care attendant service providers must meet all of the following requirements:

(1) Be at least eighteen years of age.

(2) Be a non-agency provider who holds a current, valid agreement as a home care attendant service provider in accordance with sections 5111.01 , 5111.02 , and 5111.8810 of the Revised Code and this rule, and complies with all rules set forth in Chapters 5101:3-45 and 5101:3-50 of the Administrative Code.

(3) Request reimbursement for the provision of home care attendant services in accordance with rule 5101:3-50-06.1 of the Administrative Code.

(4) Not be the consumer's authorized representative.

(5) Not be the consumer's legally responsible family member as that term is defined in rule 5101:3-45-01 of the Administrative Code.

(6) Not be the consumer's legal guardian or foster caregiver.

(7) Not be the consumer's authorizing health care professional.

(8) Be identified as the provider, and have specified on the consumer's all services plan that is prior-approved by ODJFS or its designee, the number of hours for which the provider is authorized to furnish home care attendant services to the consumer.

(9) Have a valid social security number, and one of the following forms of identification:

(a) Alien identification;

(b) State of Ohio identification;

(10) Be able to read, write, and understand English at a level that enables the provider to comply with all requirements set forth in the administrative rules governing the transitions carve-out waiver.

(11) Be able to effectively communicate with the consumer.

(12) Enter into a medicaid provider agreement with ODJFS to provide home care attendant services to consumers enrolled on the transitions carve-out waiver. In order for ODJFS to approve an individual's application to become a home care attendant, the individual shall do all of the following:

(a) Comply with the medicaid provider requirements set forth in division 5101:3 of the Administrative Code.

(b) Comply with the ODJFS-administered waiver service provider requirements set forth in Chapters 5101:3-45 and 5101:3-50 of the Administrative Code.

(c) Agree to comply with the requirements set forth in sections 5111.88 to 5111.8810 of the Revised Code and all requirements set forth in this rule.

(d) Provide ODJFS with evidence to its satisfaction of all of the following:

(i) The home care attendant submits the JFS 02389 "Home Care Attendant Medication Authorization Form" (7/10) and/or JFS 02390 "Home Care Attendant Skilled Task Authorization Form" (7/10) as prescribed by paragraph (F)(2) of this rule.

(ii) The home care attendant provider either meets the personnel qualifications specified in 42 C.F.R. 484.4 (as in effect on the effective date of this rule) for home health aides, or has successfully completed at least one of the following:

(a)A competency evaluation program, or training and competency evaluation program approved or conducted by the Ohio department of health under section 3721.31 of the Revised Code; or(b)A training program approved by ODJFS that includes training in at least all of the following and provides training equivalent to a training and competency evaluation program specified in paragraph (E)(12)(d)(ii)(a) of this rule, or meets the requirements of 42 C.F.R. 484.36(a) (as in effect on the effective date of this rule):

(i) Basic home safety;

(ii) Universal precautions for the prevention of disease transmission, including hand-washing, and proper disposal of bodily waste and medical instruments that are sharp or may produce sharp pieces if broken;

(iii) Consumer-specific personal care aide services; and(iv) The labeling, counting and storage requirements for schedule II, schedule III, schedule IV, and schedule V medications.

(iii) Prior to beginning home care attendant services, the home care attendant received training and instruction about how to deliver the specific home care attendant services authorized by the consumer's authorizing health care professional. The training shall be consumer-specific and may be provided by the consumer's authorizing health care professional, and/or the consumer or the authorized representative in cooperation with the consumer's licensed health care professional as indicated on the JFS 02389 "Home Care Attendant Medication Authorization Form" (7/10) and/or JFS 02390 "Home Care Attendant Skilled Task Authorization Form" (7/10), as appropriate.

(iv) Upon request of the consumer or the consumer's authorizing health care professional, the home care attendant has performed a successful return demonstration of the home care attendant service to be provided.

(v) The home care attendant has obtained a certificate of completion of a course in first aid that:

(a)Is not provided solely through the internet;

(b)Includes hands-on training provided by a certified first aid instructor; and(c)Requires the individual to perform a successful return demonstration of what was learned in the course.

(vi) The home care attendant has received education from the authorizing health care professional about health and welfare considerations appropriate for an individual or group setting.

(13) Provide home care attendant services for one individual, unless authorized to provide services in a group setting in accordance with paragraph (E)(14) of this rule.

(14) The home care attendant may provide services to two or three consumers in a group setting on a case-by-case basis. Authorization is subject to approval based on a clinical review conducted by ODJFS in consultation with the consumer, authorized representative, authorizing health care professional, case manager, and multidisciplinary team. The clinical review will address the consumers' needs and desires, the skill level and training needs of the home care attendant, and the ability to assure the consumers' health and welfare.

(15) The home care attendant shall secure the services of an RN, in agreement with the consumer or authorized representative, and participate in a face-to-face visit every ninety days with the consumer, authorized representative, and the RN for the purpose of monitoring the consumer's health and welfare. During the face-to-face visit, the RN shall serve as a resource for the purpose of answering any questions the home care attendant, consumer, and/or authorized representative have about consumer care needs, medications, and other issues.

(a) The first visit between the home care attendant and the RN shall occur upon the initiation of home care attendant services. The case manager shall also be present at the first visit.

(b) The home care attendant and the RN shall document the activities of the visit in the consumer's clinical record.

(c) The home care attendant shall discuss the results of the face-to-face visit with the case manager and the consumer and/or authorized representative.

(16) Completes at least twelve hours of in-service continuing education regarding home care attendant services annually. Evidence of completion must be submitted to ODJFS no later than the annual anniversary of the issuance of the home care attendant's initial medicaid provider agreement. Continuing education topics include, but are not limited to, consumer health and welfare, cardiopulmonary resuscitation (CPR), patient rights, emergency preparedness, communication skills, aging sensitivity, developmental stages, nutrition, transfer techniques, disease-specific trainings, and mental health issues.

(F) A home care attendant shall not provide home care attendant services until:

(1) The consumer and/or authorized representative chooses to receive home care attendant services from a non-agency provider and complies with the requirements set forth in rule 5101:3-45-03 of the Administrative Code.

(2) ODJFS receives a JFS 2389 "Home Care Attendant Medication Authorization Form" (7/10) and/or a JFS 02390 "Home Care Attendant Skilled Task Authorization Form" (7/10), as appropriate, that contains all of the following:

(a) Written consent from the consumer or the authorized representative allowing the home care attendant to provide home care attendant services, and assuming responsibility for directing the home care attendant. When an authorized representative is directing the home care attendant, the authorized representative shall be present and awake during the delivery of home care attendant services.

(b) Written consent from the consumer's authorizing health care professional attesting that the consumer or the authorized representative has demonstrated the ability to direct the home care attendant. The written consent shall also indicate that the home care attendant has demonstrated the ability to furnish the consumer-specific home care attendant service to the consumer. The consent shall include all of the following:

(i) The consumer's name and address;

(ii) A description of the specific nursing task or self-administration of medication that the home care attendant will assist the consumer with, including, in the case of assistance with self-administration of medication, the name, dosage, and route of administration of the medication;

(iii) The times or intervals when the home care attendant is to assist the consumer with the self-administration of each dosage of the medication or with the performance of nursing tasks;

(iv) The dates on which the home care attendant is to begin and cease providing assistance;

(v) A list of severe adverse reactions that the home care attendant must report to the consumer's health care professional should the consumer experience one or more reactions;

(vi) At least one telephone number at which the home care attendant can reach the consumer's health care professional in an emergency for consultation after contacting emergency personnel;

(vii) At least one fax number at which the home care attendant can reach the consumer's authorizing health care professional when the home care attendant observes that scheduled medication(s) is missing or cannot be reconciled; and

(viii) Instructions the home care attendant must follow when assisting the consumer with the performance of a nursing task or the self-administration of medications, including, but not limited to, instructions for maintaining sterile conditions and for the storage of task-related equipment and supplies.

(G) Upon initiation of services, the consumer and/or authorized representative and case manager shall participate in the development and maintenance of a written back-up plan. The authorizing health care professional and/or the home care attendant may also participate in the development and maintenance of the back-up plan.

(1) The back-up plan shall meet the needs of the consumer in the event:

(a) The regularly scheduled home care attendant cannot or does not meet his or her obligation to provide services to the consumer; or

(b) The consumer and/or authorized representative is not able to direct home care attendant services.

(2) As authorized by the case manager,

(a) Waiver nursing as set forth in rule 5101:3-50-04 of the Administrative Code, and/or private duty nursing or home health nursing as set forth in Chapter 5101:3-12 of the Administrative Code, may be used as back-up to provide assistance with self-administration of medications and the performance of nursing tasks;

(b) Personal care aide services as set forth in rule 5101:3-50-04 of the Administrative Code may be used as back-up for personal care aides tasks; and

(H) All home care attendants must maintain a clinical record for each consumer served in a manner that protects the consumer's privacy and the confidentiality of these records. Home care attendants must maintain the clinical records at their place of business, and maintain a copy in the consumer's residence. For the purposes of this rule, the place of business must be a location other than the consumer's residence. The clinical record must contain the information listed in paragraphs (H)(1) to (H)(12) of this rule.

(1) Consumer identifying information including, but not limited to, name, address, age, date of birth, sex, race, marital status, significant phone numbers, and health identification numbers.

(2) Consumer medical history.

(3) Name of, and contact information for all of the consumer's licensed health care professionals.

(4) A copy of the initial and all subsequent all services plans.

(5) Documentation of all drug and food interactions, allergies, and dietary restrictions.

(6) A copy of any advance directives including, but not limited to, a "do not resuscitate order" ("DNR") or a "medical power of attorney" if they exist.

(7) The JFS 2389 "Home Care Attendant Medication Authorization Form" (7/10) and/or a JFS 02390 "Home Care Attendant Skilled Task Authorization Form" (7/10), as appropriate.

(8) Documentation of home care attendant services performed or not performed, arrival and departure times, and the dated signature of the provider, and consumer or authorized representative, verifying the service delivery upon its completion. Nothing shall prohibit the collection and maintenance of documentation through technology-based systems. The consumer's or authorized representative's signature of choice shall be documented on the all services plan, and shall include, but not be limited to, any of the following: a handwritten signature, initials, a stamp or mark, or an electronic signature.

(9) A copy of the log detailing the count and reconciliation of schedule II, schedule III, schedule IV, and schedule V drugs for which assistance with self-administration is provided.

(10) Progress notes signed and dated by the home care attendant, documenting all communications with the case manager, licensed health care professionals including the authorizing health care professional, other members of the multidisciplinary team, and documenting any unusual events occurring during the visit, and the general condition of the consumer.

(11) Documentation of the face-to-face visits occurring every ninety days between the home care attendant, consumer, authorized representative, and RN, and any resulting activities, in accordance with paragraph (E)(15) of this rule.

(12) A discharge summary, signed and dated by the departing home care attendant at the point the home care attendant is no longer going to provide services to the consumer, or when the consumer no longer wants or needs home care attendant services. The summary should include documentation regarding progress made toward achievement of goals as specified on the all services plan.

(I) If ODJFS or its designee determines that the consumer and/or authorized representative cannot meet the requirements of this rule, or the health and welfare of the consumer receiving home care attendant services cannot be assured, then ODJFS or its designee may prohibit the consumer from receiving home care attendant services. The consumer shall be afforded notice and hearing rights in accordance with division 5101:6 of the Administrative Code.

(J) A home care attendant who provides home care attendant services to a consumer in accordance with the limitations set forth in this rule, including activities in accordance with the authorizing health care professional's authorization, shall not be considered to be engaging in the practice of nursing as an RN or an LPN in violation of section 4723.03 of the Revised Code.

(1) The consumer who is receiving home care attendant services, the authorized representative, or a provider shall report to ODJFS all instances in which a home care attendant appears to have:

(a) Provided nursing services, other than assistance with self-administration of medication or the performance of nursing tasks as authorized in this rule; or

(b) Provided services not in accordance with the authorizing health care professional's authorization.

(2) ODJFS may initiate an investigation based on the report, and shall report its findings to the Ohio board of nursing.

Effective: 07/01/2010
R.C. 119.032 review dates: 07/01/2015
Promulgated Under: 119.03
Statutory Authority: 5111.85 , 5111.88
Rule Amplifies: 5111.01 , 5111.02 , 5111.88 , 5111.881 , 5111.882 ,
5111.883 , 5111.884 , 5111.885 , 5111.886 , 5111.887 , 5111.888 , 5111.889 , 5111.8810

5160-50-05 [Rescinded] Transitions carve-out waiver program: calculation of the individual cost cap.

Effective: 07/03/2014
R.C. 119.032 review dates: 04/16/2014
Promulgated Under: 119.03
Statutory Authority: 5166.02
Rule Amplifies: 5162.03 , 5164.02 and 5166.02
Prior Effective Dates: 7/1/98 and 2/15/07

5160-50-06 Transitions carve-out waiver program: reimbursement rates and billing procedures.

(A) Definitions of terms used for billing and calculating rates.

(1) "Base rate," as used in table A, column 3 of paragraph (B) of this rule, means the amount paid for up to the first four units of service delivered.

(2) "Billing unit," as used in table B, column 3 of paragraph (B) of this rule, means a single fixed item, amount of time or measurement (e.g., a meal, a day, or mile, etc.).

(3) "Group rate," as used in paragraph (E)(1) of this rule, means the amount that waiver nursing and personal care aide service providers are reimbursed when the service is provided in a group setting.

(4) "Group setting" means a situation where a waiver nursing and/or personal care aide service provider furnishes the same type of services to two or three individuals at the same address. The services provided in the group setting can be either the same type of ODJFS-administered waiver service, or a combination of ODJFS-administered waiver services and similar non-ODJFS-administered waiver services.

(5) "Medicaid maximum rate" means the maximum amount that will be paid by medicaid for the service rendered.

(a) For the billing codes in table B of paragraph (B) of this rule, the medicaid maximum rate is set forth in column (4).

(b) For the billing codes in table A of paragraph (B) of this rule, the medicaid maximum rate is:

(i) The base rate as defined in paragraph (A)(1) of this rule, or

(ii) The base rate as defined in paragraph (A)(1) of this rule plus the unit rate as defined in paragraph (A) (7) of this rule for each additional unit of service delivered.

(6) "Modifier," as used in paragraph (E) of this rule, means the additional two-alpha-numeric-digit billing codes that providers are required to use to provide additional information regarding service delivery.

(7) "Unit rate," as used in table A, column 4 of paragraph (B) of this rule, means the amount paid for each fifteen minute unit following the base rate paid for the first four units of service provided.

(B) Billing code tables.

Table A

Column 1	Column 2	Column 3	Column 4
Billing code	Service	Base rate	Unit rate
T1002	Waiver nursing services provided by an agency RN	$ 52.20	$ 5.69
T1002	Waiver nursing services provided by a non-agency RN	$ 41.76	$ 5.69
T1003	Waiver nursing services provided by an agency LPN	$ 52.20	$ 5.69
T1003	Waiver nursing services provided by a non-agency LPN	$ 41.76	$ 5.69
T1019	Personal care aide services provided by an agency personal care aide	$ 23.26	$ 3.00
T1019	Personal care aide services provided by a non-agency personal care aide	$ 18.61	$ 3.00

Table B

Column 1	Column 2	Column 3	Column 4
Billing code	Service	Billing unit	Medicaid maximum rate
H0045	Out-of-home respite services	Per day	$ 199.82
S0215	Supplemental transportation services	Per mile	$ 0.38
S5101	Adult day health center services	Per half day	$ 32.48
S5102	Adult day health center services	Per Day	$ 64.94
S5160	Emergency response services	Per installation and testing	$ 44.96
S5161	Emergency response services	Per monthly fee	$ 44.96
S5165	Home modification services	Per item	Amount prior-authorized on the all services plan
T2029	Supplemental adaptive and assistive device services	Per item	Amount prior-authorized on the all services plan
S5170	Home delivered meal services	Per meal	$ 6.99

(C) In order for a provider to submit a claim for transitions carve-out waiver services, the services must be provided in accordance with Chapters 5101:3-45 and 5101:3-50 of the Administrative Code.

(D) The amount of reimbursement for a service shall be the lesser of the provider's billed charge or the medicaid maximum rate.

(E) Required modifiers.

(1) The "HQ" modifier must be used when a provider submits a claim for billing code T1002, T1003 or T1019 if the service was delivered in a group setting. Reimbursement at a group rate shall be the lesser of the provider's billed charge or seventy-five per cent of the medicaid maximum.

(2) The "U1" modifier must be used when a provider submits a claim for billing code T1002 and the consumer is receiving infusion therapy.

(3) The "U2" modifier must be used when the same provider submits a claim for billing code T1002, T1003 or T1019 for a second visit to a consumer for the same date of service.

(4) The "U3" modifier must be used when the same provider submits a claim for billing code T1002, T1003 or T1019 for three or more visits to a consumer for the same date of service.

(5) The "U4" modifier must be used when a provider submits a claim for billing code T1002, T1003 or T1019 for a single visit that was more than twelve hours in length but did not exceed sixteen hours.

(F) Claims shall be submitted to, and reimbursement shall be provided by, the Ohio department of job and family services in accordance with Chapter 5101:3-1 of the Administrative Code.

Effective: 10/01/2011
R.C. 119.032 review dates: 01/01/2015
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.0213 , 5111.85
Rule Amplifies: 5111.02 , 5111.021 , 5111.0213 , 5111.85
Prior Effective Dates: 1/1/04, 7/1/06, 7/1/08, 1/1/10, 4/1/11

5160-50-06.1 Transitions carve-out waiver program: home care attendant services reimbursement rates and billing procedures.

(A) Definitions of terms used for billing and calculating home care attendant services (HCAS) rates.

(1) "Base rate," as set forth in column 3 of tables A and B of this rule, means the amount paid to a provider for up to four units of HCAS delivered. The base rate accounts for up to four units of assistance with self-administration of medications and the performance of nursing tasks provided during a single visit.

(2) "Continuous nursing" means nursing services (waiver nursing and/or private duty nursing) that are more than four hours in length and during which personal care aide tasks as described in paragraph (B)(1) of rule 5101:3-50-04 of the Administrative Code may be provided incidental to nursing services.

(3) "Group rate" means the amount that HCAS providers shall be reimbursed when the service is provided in a group setting.

(4) "Group setting" means a situation in which an HCAS provider furnishes HCAS in accordance with rule 5101:3-50-04.1 of the Administrative Code, and as authorized by the Ohio department of job and family services(ODJFS), to two or three individuals who reside at the same address.

(5) "HCAS visit" is a visit during which HCAS is provided in accordance with rule 5101:3-50-04.1 of the Administrative Code. An HCAS visit shall not exceed twelve hours or forty-eight units in duration.

(6) "Intermittent nursing" means nursing services (waiver nursing and/or home health nursing) that are four hours or less in length.

(7) "Medicaid maximum rate" means the maximum amount that shall be paid by the Ohio medicaid program for the service rendered. The base rate in column 3 and the unit rate in column 4 of table A of this rule, and the base rate in column 3 and the unit rates in column 5 of table B of this rule represent the medicaid maximum rates for HCAS.

(8) "Modifier" means the additional two-alpha-numeric-digit billing code set forth in paragraph (H) of this rule that HCAS providers shall use to provide additional information regarding service delivery.

(9) "Unit rate," as set forth in column 4 of table A of this rule and column 5 of table B of this rule, means the amount paid for each fifteen-minute unit of HCAS following the base rate paid for the first four units of HCAS provided.

(B) Providers shall bill for reimbursement using table A when HCAS is provided in lieu of continuous nursing as described in paragraph (A)(2) of this rule. Personal care aide tasks are included in the unit rate.

Table A

Column 1	Column 2	Column 3	Column 4
Billing code	Home care attendant service description	Base rate	Unit rate
S5125	Assistance with self-administration of medications and/or the performance of nursing tasks (HCAS/N)	$ 25.89	$ 4.17 per fifteen minute unit of HCAS/N delivered during visit (beginning with the fifth unit of service)

(C) Providers shall bill for reimbursement using table B when HCAS is provided in lieu of intermittent nursing as described in paragraph (A)(6) of this rule. The first four units of HCAS shall be billed for at the base rate. Beginning with the fifth unit of HCAS, assistance with self-administration of medications and the performance of nursing tasks (HCAS/N) shall be billed at the HCAS/N unit rate; and personal care tasks (HCAS/PC) shall be billed at the HCAS/PC unit rate using the U8 modifier.

Table B

Column 1	Column 2	Column 3	Column 4	Column 5
Billing code	Home care attendant service description	Base rate	Modifier	Unit rate
S5125	HCAS/N	$ 25.89	N/A	$ 4.17 per fifteen minute unit of HCAS/N delivered during the visit (beginning with the fifth unit of service)
S5125	HCAS/PC	N/A	U8	$ 3.00 per fifteen minute of HCAS/PC delivered during the visit

(D) In order for a provider to submit a claim for HCAS under the transitions carve-out waiver, the services must be provided in accordance with Chapters 5101:3-45 and 5101:3-50 of the Administrative Code.

(E) The amount of reimbursement for a service shall be the lesser of the provider's billed charge or the medicaid maximum rate.

(F) When HCAS/N and HCAS/PC are provided during an uninterrupted period of time, the visit shall be considered a single HCAS visit. An HCAS provider is entitled to only one base rate during an HCAS visit.

(G) HCAS providers shall be limited to a maximum of twelve hours or forty-eight units of HCAS during a twenty-four-hour period, regardless of the number of consumers served.

(H) Required modifiers.

(1) The "HQ" modifier must be used when a provider submits a claim if HCAS was delivered in a group setting. Reimbursement at a group rate shall be the lesser of the provider's billed charge or seventy-five per cent of the medicaid maximum rate.

(2) The "U2" modifier must be used when a provider submits a claim for a second HCAS visit to a consumer for the same date of service.

(3) The "U3" modifier must be used when the same provider submits a claim for three or more HCAS visits to a consumer for the same date of service.

(4) The "U8" modifier must be used when a provider submits a claim for an HCAS visit that is in lieu of intermittent nursing as described in paragraph (A)(6) of this rule, and for units of service that are HCAS/PC.

(I) Claims shall be submitted to, and reimbursement shall be provided by, the Ohio department of job and family services in accordance with Chapter 5101:3-1 of the Administrative Code.

Effective: 10/01/2011
R.C. 119.032 review dates: 07/01/2015
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.0213 , 5111.85 , 5111.8811
Rule Amplifies: 5111.02 , 5111.021 , 5111.0213 , 5111.85 , 5111.88 , 5111.881 , 5111.882 , 5111.883 , 5111.884 , 5111.885 , 5111.886 , 5111.887 , 5111.888 , 5111.889 , 5111.8810
Prior Effective Dates: 7/1/10