Home and Community Support Services (HCSS)
Home and Community Support Services (HCSS) are utilized when oversight and/or supervision as a discrete service is necessary to maintain the health and welfare of the participant living in the community. Oversight and/or supervision may be needed for safety monitoring to prevent an individual from harmful activities (for example wandering or leaving the stove on unattended). Oversight and/or supervision can be accomplished through cueing, prompting, direction and instruction. If the applicant/participant does not require oversight and/or supervision, HCSS would not be appropriate.
HCSS can also be provided to participants needing oversight and/or supervision who also require assistance with personal care services. Personal Care services is defined as some or total assistance with Activities of Daily Living (ADL) such as dressing, bathing, hygiene/grooming, toileting, ambulation/mobility, transferring and eating, and/or Instrumental Activities of Daily Living (IADL) such as housekeeping, shopping, meal preparation, laundry, transportation and telephone use essential to the maintenance of the participant's health and welfare in the community. HCSS can support this as long as the discrete oversight and/or supervision component is needed.
Since HCSS staff must be trained to the Personal Care Aide (PCA) Level, they will be able to perform the scope of personal care tasks and functions necessary for an individual who also requires oversight and/or supervision. The HCSS worker is never allowed to exceed this scope of practice.
HCSS is complementary but not duplicative of other services. HCSS is not to be used as a companion service.
NOTE: If a participant's oversight/supervision needs warrant HCSS during the night, the HCSS staff must remain awake throughout the duration of time assigned to the participant to assure the appropriate level of oversight/supervision is provided.
Once it is determined that a referral for HCSS will be pursued, the applicant/participant should select an HCSS provider from the list of qualified agencies provided by the SC. The SC contacts the selected HCSS provider to request an assessment.
NOTE: If the applicant/participant does not require oversight and/or supervision, he/she may still need to be assessed for assistance with personal care or higher skilled needs. Such assistance may be available from informal supports or a referral to State Plan services may be needed. If the individual appears to need assistance with ADLs and IADLs, the applicant/participant with needs that can not be met through informal supports, must be assessed for personal care services. The SC will need to work with the applicant/participant's physician and LDSS to assure the necessary evaluation is completed and needed services arranged.
If an applicant/participant's personal care needs are being met through the provision of HCSS under the waiver, that individual cannot receive LDSS prior authorized Personal Care Services. This is true for both the traditional model of LDSS authorized personal care or the Consumer Directed Personal Assistance Program (CDPAP) model.
The RRDS and/or SC may identify that the applicant/participant requires the provision of skilled tasks such as those provided under Certified Home Health Agency services or Private Duty Nursing. These tasks are not included in this waiver service. They are potentially provided to Medicaid recipients through Certified Home Health Agencies (CHHA), Private Duty Nursing or the CDPAP. CDPAP may be used for the delivery of skilled services. In cases involving a combination of HCSS and CDPAP for skilled services, the SC must clearly articulate in the SP the justification of the need for CDPAP and the task(s) CDPAP is providing to the participant.
If an applicant/participant requires HCSS due to the need for discrete oversight and/or supervision, this is an indicator that the individual is not self-directing and requires an appointed self-directed other to manage the CDPAP services. To avoid conflict of interest the individual's HCSS worker, current NHTD waiver service providers, and/or NHTD contract staff (e.g. RRDS, NE and QMS) can not serve as a self-directing other. In addition, any individual associated with an agency delivering Medicaid reimbursed services to the participant can not serve as the self-directing other.
If the SC determines that the applicant/participant may be in need of HCSS, the SC discusses the need for an assessment by a provider of HCSS with the applicant/participant. The SC provides the applicant/participant with a list of available HCSS providers to select from. Upon selection of the HCSS provider, the applicant/participant completes the Provider Selection form. The SC contacts the selected HCSS provider and forwards the Provider Selection form to that agency. The HCSS provider completes and returns the Provider Selection form to the SC.
The SC completes the designated sections of the Home Assessment Abstract (DSS-3139) (refer to Appendix F) and forwards the tool to the selected HCSS provider's supervising Registered Professional Nurse for completion. Upon receipt of the Home Assessment Abstract (DSS-3139) from the SC, the HCSS provider's Registered Professional Nurse must complete the appropriate nursing-related sections of the Home Assessment Abstract (DSS-3139) and return the completed tool to the SC within (14) calendar days. The Registered Professional Nurse must include in the Home Assessment Abstract (DSS-3139) documentation supporting the need for oversight and/or supervision. In addition, there must be clearly documented recommendations for the amount, frequency and duration of HCSS for the participant and identification of any additional areas of support needed. The completed assessment tool must be provided to the SC for review with the applicant/participant and to be included in the SP. As per usual practice, the RRDS has the final determination regarding the amount, frequency and duration of HCSS to be provided.
For an applicant/participant who is in a nursing home or hospital at the time the assessment is conducted, the NHTD SC and the selected agency's supervising Registered Professional Nurse will need to complete the Home Assessment Abstract (DSS-3139) tool. For the section of the tool regarding the home environment, it is necessary to access the participant's residence. However, if this can not be done prior to discharge from the hospital or nursing home, it must be completed on the first day HCSS is scheduled to begin. In this situation, HCSS may be approved to begin by the RRDS based on the information available in the preliminary HCSS assessment.
The provider of HCSS must assure that orders from the participant's medical practitioner have been acquired in support of the need for HCSS as approved in the SP. This order must include documentation of the need for oversight and/or supervision as a discrete service based on medical diagnosis.
Under the NHTD waiver, the selected provider's supervising Registered Professional Nurse will be responsible for supervising HCSS staff. The selected provider's supervising Registered Professional Nurse must conduct an initial home visit on the day and time HCSS staff begins providing services to the participant. The focus of this visit is for the selected provider's supervising Registered Professional Nurse to introduce the staff to the participant, assure services established during the initial assessment continue to be sufficient and, if necessary complete the environmental portion of the preliminary assessment tool. Any changes indicated will be communicated to the NHTD SC and/or MD as appropriate. If a particular activity requires on-the-job training, the selected provider's supervising Registered Professional Nurse will provide it during this visit.
Often times, when HCSS is being utilized, there may be other services involved, for example ILST, and/or Positive Behavioral Intervention and Support (PBIS) and other waiver service providers assisting the participant to work toward his/her goals. For example, if ILST is utilized, an assessment will be completed and a Detailed Plan developed for cueing, prompting or supervising the participant in ADLs and IADLs. The ILST will work cooperatively with the selected provider's supervising Registered Professional Nurse and HCSS staff to assure implementation of the Detailed Plan and provide needed guidance and/or additional training. Another example is the PBIS Specialist who may also train the HCSS staff in behavioral interventions based on a Detailed Plan. The provision of these types of complementary trainings will serve to enhance the level of consistency, cooperation, communication and team work between providers and the participant.
It is important to consider the interests and needs of the waiver participant when assigning HCSS support. The ability of the HCSS staff to support the strengths, interests and needs of the participant will promote a better working relationship and help to meet the established goals for the service. It is the right of the participant to request a change in HCSS staff. Attempting to find the best match between the HCSS staff and participant from the start decreases the occurrence of staff turnover and Serious Reportable Incidents (SRI) while increasing participant satisfaction and success in the community.
Given the critical need for continuity in oversight and/or supervision, HCSS providers are reminded of their responsibility for assuring sufficient back-up for the HCSS staff.
HCSS may only be provided by a Licensed Home Care Services Agency (LHCSA). All regulations governing the LHCSA will be in effect for the provision of this service, e.g. patient rights, patient service policies and procedures, plan of care, medical orders, clinical supervision, patient care records, governing authority, contracts, personnel, and records and reports.
Key requirements for HCSS staff members include that such staff must:
- Be at least 18 years old;
- Be able to follow written and verbal instructions;
- Have the ability and skills necessary to meet the waiver participant's needs that will be addressed through this service;
- Have a certificate to indicate that they have successfully completed a forty (40)-hour training program for Level II PCAs that is approved by DOH;
- Attend the approved DOH curriculum entitled "Home and Community Support Services 101"prior to providing billable services, and any additional training required by DOH;
- Attend six (6) hours of in-service education per year which includes NHTD waiver-specific training; and
- Be in good physical health; including health and immunization requirements as per LHCSA regulations.
The selected provider's supervising Registered Professional Nurse must:
- be licensed by the NYS Education Department pursuant to Article 139 of the NYS Education Law and is currently certified to practice as a registered professional nurse in New York State;
- be in good physical health that the Department of Health requires for employees of certified home health agencies that includes documentation of a yearly physical exam, immunizations, a yearly Mantoux skin test and a declaration that one is free from health impairments which pose potential risks to patients or personnel; and
- meet one of the following qualifications:
- have at least two years satisfactory recent home health care experience; or
- (2) have a combination of (a) and (b), with at least one year of home health care experience and acts under the direction of an individual who meets the qualifications listed in (a) and (b) and (1) of this section.
The HCSS agency must have available a communication system for 24 hours/ seven days per week coverage to assure any issues regarding a participant's services can be addressed.
HCSS services, including both direct care and selected provider's supervising Registered Professional Nurse Visits, must be provided by a DOH approved provider and included in the SP to be reimbursed.
HCSS services are reimbursed on an hourly basis. When HCSS is provided to more than one person at a time, the ratio of provider to participants must be stated in the SP and the billing must be prorated. Example: HCSS is providing services to two individuals living together for six hours. The SP for each individual reflects a 1:2 ratio and billing reflects three hours per person.
HCSS staff must attend Team Meetings. However, the provider may claim reimbursement for only one agency representative attending a Team Meeting.
The assessment of the applicant/participant for the need for HCSS and providing recommendations for HCSS is considered an administrative cost and, therefore, is not discretely billable. The selected provider's supervising Registered Professional Nurse Visit made on the day the HCSS begins is billable on a per visit basis. This visit will result in the development of the Detailed Plan and if necessary, provide an opportunity for the completion of the environmental section of the preliminary assessment.
Subsequent visits made by the selected provider's supervising Registered Professional Nurse for supervision or on-the-job training of the HCSS staff are considered administrative costs and, therefore, are not billable.
A selected provider's supervising Registered Professional Nurse Visit made six (6) weeks prior to the development of a RSP to re-evaluate the participant for the continued need for HCSS and to complete the Individual Service Report (ISR) is a billable visit.