11 OHIP/ADM-6 - Consumer Directed Personal Assistance Program (CDPAP) Scope and Procedures
To: Commissioners of Social Services
Subject: Consumer Directed Personal Assistance Program (CDPAP) Scope and Procedures
Date: September 12, 2011
Suggested Distribution: Director of Social Services, Medicaid Staff, Home Care Staff
Contact Person: Bureau of Quality Assurance & Licensure Division of Home & Community Based Services Home Care District Liaison (518)474-5888
- Previous ADMs/INFs: GIS 10 OLTC/009, GIS 10 OLTC/005, GIS 09 OLTC/005, GIS 08 OLTC/007, GIS 08 OLTC/005, GIS 06 MA/030, GIS 04 MA/010, GIS 02 MA/024, 06 OMM/LCM-2, 06 OMM/LCM-1, 92 ADM-15, 96 LCM-31, 95 LCM-102
- Releases Cancelled: None
- Department Regulations: 18 NYCRR §505.28, 18 NYCRR §504.3, 10 NYCRR §766.11
- Social Service Law & Other Leagal References: SSL 365-f
- Manual References: None
- Miscellaneous References: None
The purpose of this administrative directive is to inform social services districts of the policies and procedures to be followed when authorizing or reauthorizing Consumer Directed Personal Assistance Program (CDPAP) services as outlined in 18 NYCRR § 505.28.
The CDPAP began as a demonstration called the Patient Managed Home Care Program (PMHCP). In 1995 it was elevated to program status and renamed CDPAP.
In 1995 the legislature passed Social Services Law 365-f establishing the CDPAP to permit chronically ill and/or physically disabled individuals receiving home care under the medical assistance program greater flexibility and freedom of choice in obtaining such services. The CDPAP is operated in New York State as a Medicaid State Plan service and the district must follow all applicable CDPAP assessment and authorization processes and policies. The scope of services that may be authorized under CDPAP include the tasks that may be provided by a Personal Care Aide, Home Health Aide, Licensed Practical Nurse or Registered Professional Nurse.
SSL Section 365-f authorizes the provision of the CDPAP and the regulatory authority is located at 18 NYCRR § 505.28. These regulations include a description of the program; eligibility requirements; the assessment/reassessment process; guidelines for the local social services districts to determine an applicant's eligibility and appropriateness for participation in the program. The regulation also delineates roles and responsibilities of program participants, local districts and the fiscal intermediary that acts as the employer of record on behalf of the consumer.
III. PROGRAM IMPLICATIONS
Districts will now be required to administer the CDPAP through adherence to 18 NYCRR § 505.28 which will ensure statewide consistency when authorizing or reauthorizing CDPAP services.
A. Self-Directing Consumer: means a consumer who is capable of making choices regarding the consumer's activities of daily living and the type, quality and management of his or her consumer directed personal assistance; understands the impact of these choices; and assumes responsibility for the results of these choices.
B. Consumer: means a medical assistance recipient who a social services district has determined eligible to participate in the consumer directed personal assistance program.
C. Consumer Directed Personal Assistant: means an adult who provides consumer directed personal assistance to a consumer under the consumer's instruction, supervision and direction or under the instruction, supervision and direction of the consumer's designated representative. A consumer's spouse, parent or designated representative may not be the consumer directed personal assistant for that consumer; however, a consumer directed personal assistant may include any other adult relative of the consumer who does not reside with the consumer or any other adult relative who resides with the consumer because the amount of care the consumer requires makes such relative's presence necessary.
D. Designated Representative: means an adult to whom a self-directing consumer has delegated authority to instruct, supervise and direct the consumer directed personal assistant and to perform the consumer's responsibilities specified in subdivision (g) of this section and who is willing and able to perform these responsibilities. With respect to a non self-directing consumer, a "designated representative" means the consumer's parent, legal guardian or, subject to the social services district's approval, a responsible adult surrogate who is willing and able to perform such responsibilities on the consumer's behalf. The designated representative may not be the consumer directed personal assistant or a fiscal intermediary employee, representative or affiliated person.
E. Stable Medical Condition: means a condition that is not expected to exhibit sudden deterioration or improvement and does not require frequent medical or nursing evaluation or judgment to determine changes in the consumer's plan of care.
F. Fiscal Intermediary: means an entity that has a contract with a social services district to provide wage and benefit processing for consumer directed personal assistants and other fiscal intermediary responsibilities
V. REQUIRED ACTIONS
A. Scope of CDPAP
CDPAP is defined as the provision of some or total assistance with personal care tasks, home health aide tasks and/or skilled nursing tasks by a consumer directed personal assistant under the instruction, supervision and direction of a consumer or the consumer's designated representative.
When the consumer requires assistance with nutritional and environmental support functions only, the hours of assistance cannot exceed eight hours a week.
B. Eligibility Requirements
To participate in the CDPAP, a consumer must meet all of the following eligibility requirements:
- Be eligible for medical assistance;
- Be eligible for long term care and services provided by a certified home health agency, long term home health care program or an AIDS home care program authorized pursuant to Article 36 of the Public Health Law; or for personal care services or private duty nursing services;
- Have a stable medical condition;
- Be self-directing or, if non self-directing, have a designated representative;
- Need some or total assistance with one or more personal care tasks, home health aide tasks or skilled nursing tasks;
- Be willing and able to fulfill the consumer's responsibilities or have a designated representative who is willing and able to fulfill such responsibilities; and
- Participate as needed, or have a designated representative who participates, in the required assessment and reassessment processes.
C. Assessment & Authorization
The social services district must conduct the social assessment and conduct or obtain a nursing assessment with reasonable promptness, generally not to exceed 30 calendar days after receiving a completed and signed physician's order. This statement applies except in unusual circumstances including, but not limited to, when the consumer or, if applicable, the consumer's designated representative has failed to participate as needed in the assessment process. The assessment should be strength based and must consider the consumer's ability to complete ADL's/IADL's. The assessors must base the determination of need on observation, discussion and documentation. The attached Assessment Information and Training Module (Attachment 1) can be shared with both social and nurse assessors for additional guidance.
1. Physician's Orders
A physician licensed in accordance with Article 131 of the NYS Education Law, a physician assistant or a specialist assistant registered in accordance with Article 131-B of the NYS Education Law or a nurse practitioner certified in accordance with article 139 of the Education Law must conduct a medical examination of the consumer and complete the physician's order within 30 calendar days after conducting the medical examination. The physician's order must be completed on a form that the Department requires or approves. The physician or other medical professional who conducted the examination must complete the order form by accurately describing the consumer's medical condition and regimens, including any medication regimens; the consumer's need for assistance with personal care tasks, home health aide tasks and skilled nursing tasks; and provide only such other information as the physician's order form requires. The medical professional who completes the order form must not recommend the number of hours of services that the consumer should be authorized to receive. In all cases, the physician's signature is required.
The physician's order form must be submitted to the social services district within 30 calendar days after the medical examination. The form may be submitted by the physician, other medical professional or by the consumer or the consumer's representative.
2. Social Assessment
Upon receipt of a completed and signed physician's order, social services district professional staff must conduct a social assessment. The social assessment form must be the LDSS-3139 or other form approved by DOH for use. The social assessment must include documentation of the following:
- A discussion with the consumer or, if applicable, the consumer's designated representative to determine the consumer's perception of his or her circumstances and preferences;
- An evaluation of the consumer's ability and willingness to fulfill the consumer's responsibilities or, if applicable, the ability and willingness of the consumer's designated representative to assume these responsibilities;
- An evaluation of the potential contribution of informal supports, such as family members or friends, to the consumer's care, which must consider the number and kind of informal supports available to the consumer;
- The ability and motivation of informal supports to assist in care;
- The extent of informal supports' potential involvement;
- The availability of informal supports for future assistance; and
- The acceptability to the consumer of the informal supports' involvement in his or her care.
3. Nursing Assessment
Upon receipt of a completed and signed physician's order, the social services district must conduct or obtain a nursing assessment. The nursing assessment must be completed by a registered professional nurse who is employed by the social services district or by a licensed or certified home care services agency under contract with the district. The nurse must have a license and current registration to practice as a registered professional nurse in New York State and at least two years of satisfactory recent experience in home health care. The nursing assessment form must be the LDSS-3139 and the DMS-1 or other form(s) approved by DOH for use.
If a consumer requires skilled tasks to be completed, at the time of the assessment, the nurse can request (depending on the task) that the individual demonstrate the procedure and/or provide a written policy/procedure that is followed detailing the task and the steps required to complete the task. In that way, the assessors have sufficient information to make an informed decision as to the ability of the responsible party to relay the information to any personal assistant.
The nursing assessment must include the following:
- A review and interpretation of the physician's order;
- The primary diagnosis code from the ICD-9-CM;
- An evaluation whether the consumer's medical condition, as described in the physician's order, would require frequent nursing diagnosis, evaluation or judgment;
- An evaluation of the personal care tasks, home health aide tasks and skilled nursing tasks that the consumer requires and whether the consumer requires some assistance or total assistance with such services or tasks;
- An evaluation, made in conjunction with the social assessment and physician's order, as to whether the consumer or, if applicable, the consumer's designated representative, is self-directing and willing and able to instruct, supervise and direct the consumer directed personal assistant in performing any needed personal care tasks, home health aide tasks and skilled nursing tasks;
- An evaluation of whether the consumer's need for assistance can be totally or partially met through the use of specialized medical equipment or supplies including, but not limited to, commodes, urinals, adult diapers, walkers or wheelchairs and whether the consumer would be appropriate for personal emergency response services (or other device);
- Development of the CDPAP Plan of Care (Attachment 2) in collaboration with the consumer or, if applicable, the consumer's designated representative, that identifies the personal care tasks, home health aide tasks and skilled nursing tasks with which the consumer needs assistance in the home, the degree of assistance required and a recommendation for the number of hours or frequency of such assistance; and
- Recommendations for authorization of services.
4. Authorization & Notice of Decision
When the social services district determines pursuant to the assessment process, that the individual is eligible to participate in the CDPAP, the district must authorize consumer directed personal assistance according to the consumer's plan of care. The district must not authorize consumer directed personal assistance unless it reasonably expects that such assistance can support the individual's health and safety in the home.
The district may authorize only the hours or frequency of services that the consumer actually requires to maintain his or her health and safety in the home. The authorization must be completed prior to the initiation of services.
No authorization may exceed six months unless the social services district has requested, and the Department has approved, authorization periods of up to twelve months. The Department may approve district requests for authorization periods of up to twelve months provided that professional staff of the social services district conducts a home visit with the consumer and, if applicable, the consumer's designated representative every six months and evaluate whether:
- The plan of care continues to meet the consumer's needs;
- The consumer or, if applicable, the consumer's designated representative continues to be willing and able to perform the consumer's responsibilities;
- The fiscal intermediary is fulfilling its responsibilities.
The social services district must provide the consumer with a copy of the plan of care that specifies the CDPAP services that the district has authorized the consumer to receive and the number of hours per day or week of such assistance.
Nothing precludes the provision of CDPAP services in combination with other services when a combination of services can appropriately and adequately meet the consumer's needs; provided, however, that no duplication of Medicaid funded services would result.
When there is a disagreement among the physician's order, nursing and social assessments, or there is a question regarding the level, amount or duration of services to be authorized, or if the case involves continuous 24-hour consumer directed personal assistance, an independent medical review of the case must be completed by the local professional director, a physician designated by the local professional director or a physician under contract with the social services district. The local professional director or designee must review the physician's order and the nursing and social assessments and is responsible for the final determination regarding the level and amount of services to be authorized. The final determination must be made with reasonable promptness, generally not to exceed five business days after receipt of the physician's order and the completed social and nursing assessments, except in unusual circumstances including, but not limited to, the need to resolve any outstanding questions regarding the level, amount or duration of services to be authorized.
Following completion of the assessment process, the local social services district must provide written notification of initial authorization, reauthorization or denial of the requested services (Attachment 3). The notification must be completed in its entirety and provide the required information regarding fair hearings. Notice should be provided to the consumer and, if applicable, the consumer's designated representative. A copy of the notice should be maintained in the consumer's case record.
The district is also responsible for entering the prior authorization for the services into the eMedNY system.
5. Reassessment & Reauthorization
Prior to the end of the authorization period, the social services district must reassess the consumer's continued eligibility for the CDPAP. The reassessment must evaluate whether the consumer or, if applicable, the consumer's designated representative satisfactorily fulfilled the consumer's responsibilities under the CDPAP. When the social services district determines, pursuant to the reassessment process, that the consumer is eligible to continue to participate in the CDPAP, the district must reauthorize CDPAP in accordance with the authorization process and provide written notice of the authorization (Attachment 3).
When the district determines that the consumer is no longer eligible to continue to participate in the CDPAP, the district must send the consumer, and if applicable, the consumer's designated representative, a timely and adequate notice of the district's intent to discontinue the CDPAP on forms required by the Department (Attachment 4). The reason for discontinuance must be reflected on the notice and supported in case record documentation.
The social services district must conduct a reassessment of the consumer when an unexpected change in the consumer's social circumstances, mental status or medical condition occurs during the authorization or reauthorization period that would affect the type, amount or frequency of consumer directed personal assistance provided during such period. The district is responsible for making necessary changes in the authorization or reauthorization, when they become aware of a change, on a timely basis in accordance with the following procedures:
- When the change in the consumer's service needs results solely from an unexpected change in the consumer's social circumstances including, but not limited to, loss or withdrawal of informal supports or a designated representative, the social services district must review the social assessment, document the consumer's changed social circumstances and make changes in the authorization or reauthorization as needed. A new physician's order and nursing assessment are not required; or
- When the change in the consumer's service needs results from a change in the consumer's medical condition, including loss of the consumer's ability to instruct, supervise or direct the consumer directed personal assistant, the social services district must obtain a new physician's order, social assessment and nursing assessment.
D. Roles & Responsibilities
A consumer or, if applicable, the consumer's designated representative has the following responsibilities under the CDPAP:
- Managing the plan of care including recruiting and hiring a sufficient number of individuals to provide authorized services that are included on the consumer's plan of care; training, supervising and scheduling each personal assistant; and assuring that each consumer directed personal assistant competently and safely performs the personal care tasks, home health aide tasks and skilled nursing tasks that are included on the consumer's plan of care; terminating the personal assistant's employment;
- Timely notifying the social services district of any changes in the consumer's medical condition or social circumstances including, but not limited to, any hospitalization of the consumer or change in the consumer's address, telephone number or employment;
- Timely notifying the fiscal intermediary of any changes in the employment status of each consumer directed personal assistant;
- Attesting to the accuracy of each consumer directed personal assistant's time sheets;
- Transmitting the consumer directed personal assistant's time sheets to the fiscal intermediary according to its procedures;
- Timely distributing each consumer directed personal assistant's paycheck, if needed;
- Arranging and scheduling substitute coverage when a consumer directed personal assistant is temporarily unavailable for any reason; and
- Entering into the Department approved CDPAP Agreement between the LDSS and the Consumer/Designated Representative with the social services district (Attachment 5) that describes the parties' responsibilities under the CDPAP.
2. Local Social Services District
Social services districts have the following responsibilities with respect to the CDPAP:
- Notifying on an annual basis, recipients of personal care services, long term home health care program services, AIDS home care program services or private duty nursing services of the availability of the consumer directed personal assistance program and affording them the opportunity to apply for the program;
- Complying with the assessment, authorization, reassessment and reauthorization procedures specified in this administrative directive;
- Receiving and promptly reviewing, the fiscal intermediary's notification to the district of any circumstances that may affect the consumer's or, if applicable, the consumer's designated representative's ability to fulfill the consumer's responsibilities under the program and making changes in the consumer's authorization or reauthorization as needed;
- Discontinuing, after timely and adequate notice, the consumer's participation in the CDPAP and making referrals to other services that the consumer may require when the district determines that the consumer or, if applicable, the consumer's designated representative is no longer able to fulfill the consumer's responsibilities under the program or no longer desires to continue in the program;
- Notifying consumers, on forms required by the Department, of the district's decision to authorize, reauthorize, increase, reduce, discontinue or deny services under the CDPAP, and of the consumer's right to request a fair hearing (Attachments 5 & 3);
- Maintaining current case records on each consumer and making such records available, upon request, to the Department or the Department's designee;
- Entering into contracts with each fiscal intermediary for the provision of fiscal intermediary responsibilities and monitoring the fiscal intermediary's performance under the contract, including reviewing the fiscal intermediary's administrative and personnel policies and recordkeeping relating to the provision of the CDPAP services and evaluating the quality of services that the fiscal intermediary provides; and
- Entering into the Department approved CDPAP Agreement between the LDSS and the Consumer/Designated Representative with the consumer or, if applicable the designated representative (Attachment 5) that describes the parties' responsibilities under the CDPAP.
3. Fiscal Intermediary
Fiscal intermediaries have the following responsibilities with respect to the CDPAP:
- Processing each consumer directed personal assistant's wages and benefits including establishing the amount of each assistant's wages; processing all income tax and other required wage withholdings; and complying with worker's compensation, disability and unemployment insurance requirements;
- Ensuring that the health status of each consumer directed personal assistant is assessed prior to service delivery pursuant to 10 NYCRR § 766.11(c) and (d) or any successor regulation;
- Maintaining personnel records for each consumer directed personal assistant, including time sheets and other documentation needed for wages and benefit processing and a copy of the medical documentation required pursuant to 10 NYCRR § 766.11(c) and (d) or any successor regulation;
- Maintaining records for each consumer including copies of the social services district's authorization or reauthorization;
- Monitoring the consumer's or, if applicable, the consumer's designated representative's continuing ability to fulfill the consumer's responsibilities under the program and promptly notifying the social services district of any circumstance that may affect the consumer's or, if applicable, the consumer's designated representative's ability to fulfill such responsibilities;
- Complying with the Department 's regulations at 18 NYCRR §504.3, or any successor regulation, that specify the responsibilities of providers enrolled in the medical assistance program;
- Entering into a contract with the social services district for the provision of fiscal intermediary services; and
- Sharing information with the consumer or, if applicable, the consumer's designated representative, regarding their respective responsibilities and requirements under the CDPAP.
E. Forms and Notices
The forms and notices below have been developed to assist the local district in the administration of the CDPAP in accordance with 18 NYCRR § 505.28 and are effective immediately:
Attachment 1 – Assessment Information and Training Module
- The purpose of this document is to familiarize staff involved in the assessment and authorization of the CDPAP for training and assessment purposes.
Attachment 2 - CDPAP Plan of Care
- The purpose of this document is to clearly identify those tasks, both skilled and unskilled, that the consumer requires. A copy of this plan should be maintained by the LDSS in the case record and provided to the consumer for use in directing the personal assistant(s) in those authorized tasks. It will be the responsibility of the CDPAP personal assistant to perform only those tasks authorized and included on the plan of care. At a minimum, this plan of care must be completed as part of each assessment/reassessment and whenever there is a change in service responsibility.
Attachment 3 - CDPAP Notice of Decision of Initial Authorization, Reauthorization, or Denial of CDPAP Services
- A completed copy of this notice must be provided to the CDPAP consumer no later than the effective date of the initial authorization, reauthorization, or denial. The same notice must be mailed to the consumer when the application for CDPAP is denied. This must be sent as a two-sided notice.
Attachment 4 - CDPAP Notice of Intent to Increase, Reduce or Discontinue CDPAP Services
- A completed copy of this notice must be mailed to the CDPAP consumer at least 10 days before the date that CDPAP services are to be increased, reduced or discontinued. This should be sent as a two-sided notice.
Attachment 5 - CDPAP Memorandum of Understanding/Agreement Between the LDSS and the Consumer/Designated Representative
- The purpose of this document is to clearly outline the responsibilities of the consumer and the LDSS and assure that both parties understand the purpose and parameters of the program. This agreement should be implemented as part of the assessment process prior to the authorization of service. A copy should be maintained in the LDSS case record and a copy must be provided to, and maintained by, the CDPAP participant. If there is a change in the consumer's ability to self-direct or a change in the self-directing other, a new agreement must be executed.
F. Maximization of Medicare and Other Third Party Insurance
Before providing CDPAP services, local social service districts shall make maximum use of home health and/or nursing services provided under Medicare or other third party insurance, whenever program eligibility conditions under those programs can be met.
The Department will pay fiscal intermediaries that are enrolled as Medicaid providers and have contracts with social services districts for the provision of CDPAP services at rates that the Department establishes and that the Director of the Division of the Budget approves, except as provided in the following paragraph.
A social services district may submit a written request to the Department to use an alternative payment methodology. The request must describe the alternative payment methodology that the district will use to determine payments to fiscal intermediaries for consumer directed personal assistance services and include such other information as the Department may require. The Department may grant a district's exemption request when it determines that the alternative payment methodology is based on the fiscal intermediary's allowable costs of providing consumer directed personal assistance services and includes an adjustment for inflationary increases in the fiscal intermediary's costs of doing business.
No payment to the fiscal intermediary will be made for authorized services unless the fiscal intermediary's claim is supported by documentation of the time spent in provision of services for each consumer.
V. EFFECTIVE DATE
This ADM is effective April 20, 2011.
Appendix I: Listing of Attachments
- Attachment 1: Assessment Information and Training Module
- Attachment 2: CDPAP Plan of Care
- Attachment 3: CDPAP Notice of Decision of Initial Authorization, Reauthorization, or Denial of CDPAP Services
- Attachment 4: CDPAP Notice of Intent to Increase, Reduce or Discontinue CDPAP Services
- Attachment 5: CDPAP Agreement Between the LDSS and the Consumer/Designated Representative
Attachment 1: ASSESSMENT INFORMATION AND TRAINING MODULE
The Medicaid (MA) funded, prior authorized Personal Care Services Program (PCSP) and the related prior authorized home care programs such as CDPAP, PERS, ALP and LLHCSA, provide eligible consumers with some or total assistance with personal hygiene, dressing and feeding and nutritional and environmental support functions and, where appropriate, health related tasks that can be provided by a home health aide and/or skilled tasks that can be provided by a Licensed Practical Nurse (LPN) or Registered Professional Nurse (RPN). The provision of such services must be medically necessary and essential to the maintenance of the consumer's health and safety in his or her own home, as determined by the social services district, or its designee, in accordance with the regulations of the Department of Health; ordered by the attending physician and based on an assessment of the consumer's needs. The overriding basis for service authorization and delivery is dependent on a thorough and adequate assessment.
Research has indicated that use of a strength-based assessment for care planning is most conducive to providing services that are supportive in nature and do not supplant or disregard the abilities and independence of the consumer seeking services. Rather than focusing on "what's wrong", a strength-based approach allows the assessor(s) to identify the positive resources and abilities of consumers and their informal supports. This can be accomplished through a culturally sensitive and individualized approach that reflects the sound casework practices of:
- Active listening;
- Empathy and respect;
- Strength-based assessment of needs and assets;
- Ongoing service planning.
It is highly recommended that the assessments and reassessments for the delivery of services utilize a strength based approach and reflect those casework practices. The provision of home care is designed to support and enhance the abilities and independence of the consumer. Assessors should not be seeking to replace self-care abilities but should be supporting those abilities.
A thorough assessment must take into consideration the abilityof the consumer to accomplish activities of daily living (ADLs) and instrumental activities of daily living (IADLs). ADLs are activities related to personal care and include bathing or showering, getting in or out of a bed or chair, ambulating, using the toilet and eating. IADLs are those activities related to independent living and include preparing meals, managing money, shopping for groceries or personal items, performing housework, and using a telephone. It is the purpose of the assessment process to determine the extent of assistance required by the consumer to perform ADLs and IADLs; the formal and informal supports currently available to assist with those activities; and the extent to which these supports will remain in place.
The initial assessment process begins with a request for service. This request can come from a variety of sources. The source of the request guides the next step in the process. For example, when the request for service is made by the consumer, the consumer is advised of the need for completed physician's orders. The agency can provide the consumer with a blank copy of the physician's order form or, at the consumer's request, can send the form directly to the consumer's primary physician for completion. However, when the request for services is made by an individual/agency other than the consumer, response to that request should only be generic (i.e. need for physician's orders, assessment process, home visit, etc.) unless the requestor has provided a release of information that allows that individual/agency to discuss the specifics of the consumer's care needs.
The initial assessments and reassessments must be based on specific regulatory requirements as follows:
- Physician's orders;
- Nursing assessment; and
- Social assessment.
For the purposes of the MA funded prior authorized home care services, receipt of physician's orders initiates the assessment process. Verbal orders or simple written requests for assessments are not acceptable. The orders must be signed and documented on a form that has been approved by the Department. The form should allow for the physician to provide medical information regarding the consumer's diagnosis, medications, and physical and mental limitations and must indicate whether or not the consumer can be cared for at home with the requested services. The form utilized by the district must not provide the completing physician with an option of requesting a specific number of hours of care.
When the case management agency receives an initial request for home care services, the consumer, or the consumer's primary physician, should be provided with a physician's
order form for completion. In order to assure that the orders reflect current medical information, all completed physician's orders for PCS should be based on a medical examination conducted within 30 days of the date the orders are completed and signed. The completed order form must then be returned to the case management agency within thirty days of the examination. Ideally, the information contained in the physician's order will reflect a link between the diagnosisand functional ability of the consumer and the need for the service.
Following receipt of the orders, the case management agency should review the orders to assure that the form has been completed in its entirety and that the physician has signed and dated the document. If the initial orders are not complete, the case management agency should have a procedure in place for returning/obtaining a completed, signed form.
The next step in the assessment process is to complete, or to arrange for completion of, a social and a nursing assessment. The time frames for initiation and completion of these assessments can be found in 18 NYCRR 505.14. It is the correlation of the information that the assessors will obtain and document during the assessment process that provides the foundation for determining the service hours required. It is recommended that the nursing and social assessments be conducted jointly to allow for consistency. The forms utilized by the MA funded PCS and related services continue to be the DSS-3139 and the DMS-1 or, in NYC, the M-11s (social assessment) and the M-11r (nursing assessment).
Districts that are not utilizing these documents must have submitted their local forms to the Department of Health, Office of Long Term Care, Division of Home and Community Based Services for review and approval prior to use. In addition, in late 2012, the Department will convert all PCSP assessments to a uniform assessment system (UAS-NY). Separate and additional training will be made available in advance of such conversion.
Social assessments for the MA funded prior authorized home care programs are conducted by professional casework staff from the local Department of Social Services, or its designee, who also have the responsibility for ongoing case management. One of the most important considerations is the evaluation of the family and community support available to enable the consumer to remain in the community. Case work staff has the responsibility of determining the extent of those supports and maintaining them through ongoing case management.
The case manager must discuss, in depth, the role that the other household members and formal and informal supports outside of the household currently play, and will continue to play, in the care and support of the consumer. That information is then documented on page 2, Sections 7, 8 and 9 of the DSS-3139. It is important to encourage and support those individuals and organizations to continue, whenever possible, their involvement with the consumer.
There are frequently multiple agencies providing services to consumers. When consumers are in receipt of other community support services that are administered by other agencies (e.g. home delivered meals, senior transportation, EISEP) or are participating in programs such as the Traumatic Brain Injury Waiver, or other Home and Community Based Services Waivers, it is the responsibility of the case manager, as an integral part of the social assessment, to contact those providers/case managers to determine their services and involvement. Without a firm knowledge base regarding these agencies and the services they provide, a decision cannot be made as to what might constitute a duplication of service. For example, if the consumer is participating in a waiver, the waiver case manager must be contacted and included in the assessment process. The waiver case manager may opt to be present during the face to face assessment or may only be available by telephone to answer questions specific to his or her program. In any case, the goals included in the consumer's individualized service plan or education plan developed and implemented under the waiver should be reviewed and considered when determining home care needs. For example, if the goal for the waiver participant is to learn to develop menus, shop for needed supplies and prepare meals, the waiver case manager would be responsible for assisting the consumer to achieve those goals and any authorization for personal care services related to shopping or meal preparation may be unnecessary or time limited. Without the important information regarding the service plan and/or goals, the nurse assessor is unable to accurately determine the unmet needs of the consumer and the tasks that must be completed by the personal care service provider.
The case manager is responsible for coordination and completion of the assessment process to ensure that all required documentation is complete. The case manager must review all information received and must evaluate the recommendations made by the assessing nurse. It is the ultimate responsibility of that case manager to determine, based on the compilation of documentation, the appropriateness of the overall plan for the consumer. If the case manager does not agree with the recommendations of the assessing nurse regarding level of care or number of hours/days a week of service, a discussion with the assessing nurse is recommended. If that conference does not resolve the differences in opinion the case, including all required documentation, must be referred to the Local Professional Director for resolution.
In addition, the recommendations for services, other than those that are prior authorized, must be reviewed and all referrals for other services (e.g. adult protective service, EISEP, home delivered meals) should be made by the case manager where appropriate.
The ongoing responsibilities of the PCS case manager are defined in 18 NYCRR § 505.14(g).
Prior to conducting the face to face assessment in the consumer's home, the assessing registered professional nurse (RPN) should have received and reviewed a copy of the completed physician's order. The information included in that document provides the RPN with basic information regarding the consumer's medical diagnosis, current medications, functional limitations and whether the consumer has the ability to self-direct. Additionally, there should be a statement as to whether the attending physician recommends the provision of PCS or related services for their patient. The assessing nurse must keep in mind that this basic medical information does not allow for the variances in function that consumers with the same diagnosis can exhibit. This information serves only as a foundation upon which to build the information gathered during the entire assessment process.
In order to participate in the MA prior authorized home care services, a consumer must require assistance with performance of ADLs and IADLs and/or, in the case of the Consumer Directed Personal Assistance Program (CDPAP), assistance with, or completion of, health related or skilled tasks that can be provided within the scope of the program.
A critical clinical intervention for consumers receiving home care services is to promote independence. In order to promote and support this independence, a key appraisal point of effective home care is the consumer's functional status and ability. Functional ability can be defined as the ability to perform self-care tasks necessary to function in society and in the community. Those self-care tasks are categorized into ADLs and IADLs as follows:
- meal planning and preparation
- use of a telephone
- managing finances
- shopping and errands
The completion of the ADLs and IADLs may be accomplished independently or may require some or total assistance from another individual in order for the consumer to remain in the community. The determination of the functional ability of the consumer to complete these ADLs and IADLs should be based on observation and should be reflected accurately on the required assessment forms.
The assessment must be conducted in the consumer's home. If the consumer is self- directing, the assessors should support and identify the consumer's expectations and desires. When the consumer is not self-directing, the individual who is acting on the consumer's behalf should be present during the assessment process. This assessment is achieved through discussion and visual observance of the consumer's ability to perform their ADLs and IADLs. The completion of the DSS-3139, or its equivalent, is designed to provide a standardized method for assessors to determine the following:
- Is the home the appropriate environment for this consumer's needs?
- What is the functional ability of this consumer?
- What services are necessary to maintain this consumer within the home setting?
Copies of the DSS-3139 and the instructions for completion are available on the OHIP Library of Official Documents in the section labeled Bureau of Medicaid Long Term Care Forms.
When assessing a consumer, it is necessary to ask open ended questions and to observe the consumer's ability to accomplish the necessary self-care tasks that will allow the consumer to remain in the community and/or his or her own home. These abilities and/or needs are listed specifically on page 4 of the DSS-3139/Services Required. For example, asking open-ended questions such as "how do you take a bath?" will provide the assessor with more information than asking the consumer "do you want help with your bath?" Requesting that the consumer show you the kitchen or the bathroom will allow the assessor to observe ambulation and transfer ability.
As the assessing nurse, you can also determine whether the consumer requires adaptive equipment or other services that can enhance independence. If the consumer indicates that bathing is difficult because he or she is unable to get into the tub, perhaps installation of grab bars will eliminate the need for an aide to assist with bathing. In another situation, the provision of a bedside commode for overnight use could increase the safety factor for a consumer who has difficulty getting to the bathroom during the night. The use of such efficiencies must be considered and utilized if the use of the efficiency does not jeopardize
the consumer's health and safety (if not contraindicated by a physician) when assessing for and determining service need. Information for assessors regarding the use of durable medical equipment, or other cost-effective options can be found in 18 NYCRR § 505.14(b)(3)(iv).
The assessing nurse must not only determine whether the consumer requires assistance but must document the frequency of the service required and the responsible informal or formal support(s) that will provide the assistance. It is not the responsibility of the PCS or CDPAP to supplant services already in place when the provider of those services is willing and able to continue to be involved but rather to serve as a support to such services.
The correct completion of the DMS-1 is based on a review of the physician's order, answers to the open-ended questions and observation of the consumer's abilities. It is important for nurse assessors to review the instructions periodically in order to accurately complete the form. For example, do not indicate that a consumer requires some assistance with eating when assistance with meal preparation is the task required.
The assessing nurse must also make sure that all documentation is consistent. If the DMS-1 indicates that the consumer is self-care with bathing then the DSS-3139 must also indicate that the individual is self-care.
In all cases, the assessment of need is based on the service requirements of the consumer only. When there are other household members who are not included in the service authorization, the common areas of the household are not the responsibility of the PCS provider. The care plan is developed to meet the needs of the consumer only. For example:
- A single mother with minor children whose needs are not being met due to parental illness or incapacity is assessed for PCS. The assessor must only consider and recommend services related to maintaining the consumer in her home. Caring for minor children or completing tasks such as laundry, shopping and meal preparation for the minor children cannot be the responsibility of the PCA. In this situation, the assessors should make a referral to the LDSS for additional assistance that may be provided through use of Title XX funds.
- An elderly woman is residing with her married daughter. The consumer is assessed as requiring assistance with all ADLs and IADLs. Included on the plan of care is housekeeping/cleaning kitchen and bathroom. These tasks are only applicable when the assistance with peripheral tasks such as bathing or meal preparation is done for the consumer. Cleaning up after using the kitchen and/or bathroom is appropriate but general cleaning of those areas would be the responsibility of the daughter or her family.
- The household consists of a husband and wife and one teenage son. The wife has a medical condition that prevents her from completing her ADLs and IADLs without assistance from another person. The husband works outside the home and the son attends school. The husband and the son are independent in their ADLs and IADLs. The assessment indicates that the wife requires assistance with bathing and is unable to do laundry or shopping or housework as a result of her functional limitations. When developing a plan of care for the wife, it must be clear that any laundry or shopping related to the other household members is not the responsibility of the PCA and is not included in the plan of care. Additionally, general household cleaning must be the responsibility of the other members of the household who are not included in the PCS authorization.
The goal of a complete and accurate assessment is to develop a plan of care that supports the independence and the abilities of the consumer. In those instances where the consumer is able to perform ADLs and IADLs independently but requires supervision or guidance in completion of those tasks, referrals to other agencies and/or service providers must be considered. It cannot be the responsibility of an MA prior authorized aide to supervise or teach a consumer how to perform their ADLs or IADLs.
The Department strongly encourages that the social and nursing assessment be completed jointly. This allows the assessors to develop a plan for service provision that supports the consumer's desire to remain in the most integrated setting possible to meet his or her needs.