This rule sets forth definitions of some services
covered by the Ohio home care waiver. This rule also sets forth the provider
requirements and specifications for the delivery of those Ohio home care waiver
services. Providers are also subject to the conditions of participation set
forth in rule 5160-44-31 of the Administrative Code. Services are reimbursed in
accordance with rule 5160-46-06 of the Administrative Code.
(A) Personal care aide
services.
(1) "Personal care
aide services" are defined as services provided pursuant to the
person-centered services plan (PCSP) that assist the individual with activities
of daily living (ADL) and instrumental activities of daily living (IADL) needs.
If the provider cannot perform IADLs, the provider will notify ODM or its
designee, in writing, of the service limitations before inclusion on the
individual's PCSP. Personal care aide services include:
(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, washing
floors and waste disposal;
(c) Paying bills and assisting with personal correspondence as
directed by the individual; and
(d) Accompanying or transporting the individual to Ohio home care
waiver services, medical appointments, other community services, or running
errands on behalf of that individual.
(2) Personal care aide
services do not include tasks performed, or services provided as part of the
home maintenance and chore services set forth in rule 5160-44-12 of the
Administrative Code.
(3) Personal care aide services do not
include services performed in excess of the number of hours approved pursuant
to the PCSP.
(4) Personal care aides will not
administer prescribed or over-the-counter medications to the individual, 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 individual self-administer medications
by:
(a) Reminding the individual when to take the medication, and
observing to ensure the individual follows the directions on the
container;
(b) Assisting the individual by taking the medication in its
container from where it is stored and handing the container to the
individual;
(c) Opening the container for an individual who is physically
unable to open the container;
(d) Assisting an individual 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 an individual 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 individual.
(5) Personal care aide services will 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.
(6) In order to be a provider and submit
a claim for reimbursement, all personal care aide service providers will meet
the following:
(a) Provide personal care aide services for one individual,
or for up to three individuals in a group setting during a face-to-face
visit.
(b) Comply with the additional applicable provider-specific
requirements as specified in paragraph (A)(7) or (A)(8) of this
rule.
(7) Medicare-certified and
otherwise-accredited agencies will ensure that personal care aides meet the
following requirements:
(a) Before commencing service delivery, the personal care aide
will:
(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. 484.80 (as
in effect on October 1, 2023), and
(ii) Obtain and maintain
first aid certification from a program that may be 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 will be initiated
immediately, and will 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,
will:
(i) Conduct a
face-to-face individual home visit explaining the expected activities of the
personal care aide, and identifying the individual's personal care aide
services to be provided.
(ii) Conduct a
face-to-face individual 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, and the individual's satisfaction with care delivery
and personal care aide performance. The visit will be documented in the
individual's record.
(iii) Discuss the evaluation of personal care aide services with
the case manager.
(d) At least twice per year, the RN will conduct RN assessment
visits in-person. All other RN assessment service visits may be conducted via
telehealth, unless the individual's needs necessitate an in-person visit.
When the RN performs an RN assessment visit, the RN will bill the state plan
nursing assessment code set forth in appendix A to rule 5160-12-08 of the
Administrative Code.
(e) Parent of minor children, spouse, and relatives
appointed legal decision making authority may only serve as direct care worker
in accordance with rule 5160-44-32 of the Administrative Code.
(8) Non-agency personal care aides will
meet the following requirements:
(a) Before commencing service delivery personal care aides will
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. 484.80 (as in effect on
October 1, 2023); or other equivalent training program. The program will
include training in the following areas:
(a) Personal care aide
services as defined in paragraph (A)(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 six hours of in-service continuing education
annually that will 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, health and welfare of the individual, 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 individual's or the individual's
authorized representative's specific personal care aide service
instructions, and perform a return demonstration upon request of the individual
or the case manager.
(d) Comply with ODM monitoring requirements in accordance with
rule 5160-45-06 of the Administrative Code.
(9) All personal care aide providers will
maintain a clinical record for each individual served in a manner that protects
the confidentiality of these records. Medicare-certified, or
otherwise-accredited agencies, will maintain the clinical records at their
place of business. Non-agency personal care aides will maintain the clinical
records at their place of business, and maintain a copy in the
individual's residence. For the purposes of this rule, the place of
business will be a location other than the individual's residence. At a
minimum, the clinical record will contain:
(a) 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 of the
individual.
(b) The medical history of the individual.
(c) The name of individual's treating
physician.
(d) A copy of the initial and all subsequent PCSP.
(e) Documentation of all drug and food interactions, allergies
and dietary restrictions.
(f) A copy of any advance directives including, but not limited
to, do not resuscitate (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 individual or
the individual's authorized representative, verifying the service delivery
upon completion of service delivery. The individual or the individual's
authorized representative's signature of choice will be documented on the
individual's PCSP, and will include 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 case manager, treating physician, other
members of the team, and documenting any unusual events occurring during the
visit, and the general condition of the individual.
(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 individual, or when the individual no longer needs personal
care aide services.
(i) The summary should
include documentation regarding progress made toward achievement of goals as
specified on the individual's PCSP and indicate any recommended follow-ups
or referrals.
(ii) The discharge
summary is not required in the event the individual dies.
(B) Adult day health center
services.
(1) "Adult day
health center services (ADHCS)" are regularly scheduled services delivered
at an adult day health center to individuals who are age eighteen or older. A
qualifying adult day health center will be a freestanding building or a space
within another building that will not be used for other purposes during the
provision of ADHCS.
(a) An adult day health center will provide:
(i) Waiver nursing
services as set forth in rule 5160-44-22 of the Administrative Code, or
personal care aide services as set forth in paragraph (A)(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 individual's dietary
requirements.
(b) An adult day health center may also provide:
(i) Skilled therapy
services as set forth in rule 5160-12-01 of the Administrative Code;
and
(ii) Transportation of
the individual to and from ADHCS.
(c) ADHCS are reimbursable at a full-day rate when five or more
hours are provided to an individual in a day. ADHCS are reimbursable at a
half-day rate when less than five hours are provided in a day.
(d) All of the services set forth in paragraphs (B)(1)(a) and
(B)(1)(b) of this rule and delivered by an adult day health center will 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 individual's PCSP.
(3) In order to be a
provider and submit a claim for reimbursement, providers of ADHCS will operate
the adult day health center in compliance with all federal, state and local
laws, rules and regulations.
(4) All providers of
ADHCS will:
(a) Comply with federal nondiscrimination regulations as set
forth in 45 C.F.R. part 80 (as in effect on October 1, 2023).
(b) Provide for replacement coverage of a loss due to theft,
property damage, and/or personal injury; and maintain a written procedure
identifying the steps an individual takes to file a liability claim. Upon
request, verification of coverage will be provided to ODM or its
designee.
(c) Maintain evidence of non-licensed direct care staff's
completion of twelve hours of in-service training every twelve
months.
(d) Ensure that any waiver nursing services provided are within
the nurse's scope of practice as set forth in rule 5160-44-22 of the
Administrative Code.
(e) Provide task-based instruction to direct care staff providing
personal care aide services as set forth in paragraph (A)(1) of this
rule.
(f) At all times, maintain a one to six ratio of paid direct care
staff to individuals.
(5) Providers of ADHCS
will maintain a clinical record for each individual served in a manner that
protects the confidentiality of these records. At a minimum, the clinical
record will contain the following:
(a) 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 of the
individual.
(b) The medical history of the individual.
(c) The name of the individual's treating
physician.
(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 individual's arrival
and departure times. The use of technology-based systems may be used in
collecting and maintaining the documentation required by this
paragraph.
(h) A discharge summary, signed and dated by the departing ADHCS
provider, at the point the individual 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 rule 5160-44-22
of the Administrative Code when the individual is provided waiver nursing
and/or skilled therapy services.
(C) 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 individual, or
a family member, or someone who resides in the same household as the
individual, that are not otherwise available through any other funding source
and that are suitable to enable the individual to function with greater
independence, avoid institutionalization, and reduce the need for human
assistance. All supplemental adaptive and assistive device services will be
prior-approved by ODM or its designee. ODM or its designee will only approve
the lowest cost alternative that meets the individual's needs as
determined during the assessment process.
(a) Reimbursement for medical equipment, supplies and vehicle
modifications will not exceed a combined total of ten thousand dollars within a
calendar year per individual.
(b) ODM or its designee will not approve the same type of medical
equipment, supplies and devices for the same individual during the same
calendar year, unless there is a documented need for ongoing medical equipment,
supplies or devices as documented by a licensed health care professional, or a
documented change in the individual's medical and/or physical condition
requiring the replacement.
(c) ODM or its designee will not approve the same type of
vehicle modification for the same individual within the same three-year period,
unless there is a documented change in the individual'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 down
payments 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 in the individual's
PCSP;
(iv) Replacement
equipment or supplies or repair of previously approved equipment or supplies
that have been damaged as a result of perceived misuse, abuse or negligence;
and
(v) Activities described
in paragraph (C)(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 individual. 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
individual and, if applicable, any other person(s) who will operate the vehicle
will provide ODM 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 individual 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.
(c) Vehicle modifications do not include:
(i) Payment toward the purchase or lease of a vehicle, except as
set forth in paragraph (C)(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 individual's all services plan.
(3) In order to be a provider and submit
a claim for supplemental adaptive and assistive device services, the provider
will:
(a) Ensure all manufacturer's rebates have been deducted
before requesting reimbursement for supplemental adaptive and assistive device
services.
(b) Ensure 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 will maintain a clinical record for each
individual they serve in a manner that protects the confidentiality of these
records. At a minimum, the clinical record will include:
(a) 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 of the
individual.
(b) The name of the individual's treating
physician.
(c) A copy of the initial and all subsequent PCSP.
(d) Documentation that clearly shows the date the supplemental
adaptive and assistive device service was provided. The use of technology-based
systems may be used in collecting and maintaining the documentation required by
this paragraph.
(5) The authorization of
supplemental adaptive and assistive device services may be combined with other
waiver services to meet the assessed needs of the individuals. In such
instances, individual waiver service limits as described in paragraph (C)(1)(a)
of this rule still apply.
(D) Supplemental transportation
services.
(1) "Supplemental
transportation services" are transportation services that are not
available through any other resource that enable an individual to access waiver
services and other community resources specified on the individual's PCSP.
Supplemental transportation services include, but are not limited to assistance
in transferring the individual 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 individual's all services
plan.
(3) Agency supplemental transportation
service providers will:
(a) Maintain a current list of drivers.
(b) Ensure all drivers providing supplemental transportation
services are age eighteen or older.
(c) Maintain a copy of the valid driver's license for each
driver.
(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 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, and certification that education was received
from the authorizing health care professional about health and welfare
considerations appropriate for an individual or group setting.
(g) Ensure drivers are not the individual's legally
responsible family member, as that term is defined in rule 5160-45-01 of the
Administrative Code.
(h) Ensure drivers are not the individual's foster
caregivers.
(4) Non-agency supplemental
transportation service providers will:
(a) Be age eighteen or older.
(b) Possess a valid driver's license.
(c) Maintain collision and liability insurance for each vehicle
used to provide supplemental transportation services.
(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) Completion and maintenance of 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, and certification that education was received from
the authorizing health care professional about health and welfare
considerations appropriate for an individual or group setting.
(f) Not be the individual's legally responsible family
member, as that term is defined in rule 5160-45-01 of the Administrative
Code.
(g) Not be the individual's foster caregiver.
(5) All supplemental transportation
service providers will maintain documentation that, at a minimum, includes a
log identifying the individual transported, the date of service, pick-up point,
destination point, mileage for each trip, and the signature of the individual
receiving supplemental transportation services, or the individual's
authorized representative. The individual's or authorized
representative's signature of choice will be documented on the
individual's PCSP and will include any of the following: a handwritten
signature, initials, a stamp or mark, or an electronic signature.
(E) OHCW covered services described in
this rule will be provided in accordance with the individual's PCSP.
