Personal Care Service 525-05-30-45

(Revised 12/1/10 ML #3252)

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Purpose

The philosophy of the Department is that personal care should be provided so as to assist the eligible client with as many activities of daily living and instrumental activities of daily living as needed and as permitted in order to maintain independence and self reliance to the greatest degree possible. Care, if appropriate, should be provided when, and as long as, the client needs it, up to 24-hour care if necessary. The client or legally responsible person,  must direct the care provided and should be involved in training and monitoring the personal care QSP as much as possible and when appropriate.

 

The informal network, especially family members, should be explored as potential informal providers of care before formal care is provided under the provisions of this chapter. Care provided by the informal network should not be replaced by formal/paid care unless it  is necessary for the client to receive such care.

  1. Personal care provided up to 24 hours per day, differs from adult family (foster) care in that personal care is provided in the client's home, and adult family (foster) care is provided in the service provider's home. If a non-relative is caring for the client on a 24-hr live in basis in the provider’s home, the service must be Adult Family Foster Care. It cannot be Personal Care service.  
  2. Live-in personal cares (daily care) is all inclusive with the exception of Respite Care.
  3. Personal care differs from respite care in that respite care is provided to relieve the primary, live-in caregiver, whereas the primary purpose of personal care is to provide the care a client needs and not to relieve the caregiver.

 

Service Eligibility, Criteria for

The individual receiving Personal Care service will meet the following criteria:

  1. Must be eligible for the SPED program and not eligible to receive Personal Cares under the Medicaid State Plan, or Family Home Care;
  2. Be at least age 18;
  3. The care needs of the client must fall within the scope of personal care service as described in this service chapter. The care needs may include a combination of Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). Either the client must have the ADLs and IADLs needs performed for him/her OR a cognitively impaired client may be able to complete the activity ONLY with supervision, guidance, or prompting.
  1. Daily Personal Cares live-in must be authorized if the provider and the client live in the same residence.
  1. Daily Personal Care is an all inclusive service and can only be combined with Respite Care. For unusual or unique circumstances, prior approval from the HCBS Program Administrator must be obtained.
  1. Who lives alone or is alone due to the employment of the primary caregiver as the incapacity of other household members.

 

Provider Need Not be Present in the Home on a 24-Hour Basis

The provision of Daily Personal Cares live-in is appropriate ONLY for clients who can be left alone for routine temporary periods of time  (e.g. part-time employment) without adverse impact to the client’s welfare and safety. The client must agree to be left alone.

 

Cognitively Impaired Clients, Services to

For cognitively impaired clients, the care plan shall identify how the daily care needs are met. During those periods of time when personal care service is not being provided, cooperative and coordinated efforts of meeting the needs of the client by the family, other informal providers, and agency providers are to be identified. The care plan must reflect the ongoing need for supervision, guidance, or prompting and must identify how the informal network entity(s) is involved to meet this primary need with the formal service network filling gaps.

 

Limits:  

  1. Clients whose providers do NOT meet the definition of Family Home Care may qualify for Personal Care Service. SPED Personal Care Service is not an option for clients when the live-in care provider is a family member.  See N.D.C.C. 50-06.2-02(4) for the definition of family member.
  2. Under Personal Care Service, payment can be made for time performing authorized personal care tasks even if performed outside the client's home as long as the cares are provided in the local trade area. The hours remain based on the care necessary in the client's home. The care provided outside the home must be within the defined scope (allowable tasks as authorized) of the service.  
  1. Exception:  When the client is required to seek essential services outside of the local trade area, contact the HCBS Program Administrator for prior approval.

 

Assisted Living Facility

A Monthly Rate Worksheet, SFN 1012, is completed for an individual to receive daily (SPED) personal care services in an assisted living facility when the client lives in a licensed assisted living facility and the provider has been approved to use the assisted living billing code.

 

The following criteria have been established for recipients in an "assisted living facility":

  1. Clients meeting one of the following criteria may have a self-employed QSP as a live-in-attendant.
  1. The provider is a family member as defined in State law for Family Home Care.
  2. The intensity of care needs cannot be met under "assisted living" (e.g. need for continuous on-site care).
  3. The assisted living personal care provider is not identified in the tenant’s rental agreement.
  1. For those clients unable to do their own meal preparation, it will be included in the "assisted living" provider's daily rate.  The provider may prepare the meal in the recipient's individual apartment or offer congregate dining.  The recipient is responsible for payment of food costs.

The Monthly Rate Worksheet, SFN 1012, for Assisted Living Facilities is used in setting the daily rate for providers of "assisted living." The HCBS Case Manager must determine what services are being provided by the Assisted Living facility as a component of their base rate which includes room and board. For those services included within the base rate, the tasks would not be recorded and calculated in the Monthly Rate Worksheet. The monthly rate worksheet applies to all clients who receive assisted living personal care services.

 

Service Activities, Authorized and Limits

  1. The service tasks/activities within the scope of this service chapter are identified on the Authorization to Provide Service, SFN 1699.
  2. For Personal Care unit rate, housework, laundry, communication, money management, shopping, and meal preparation are considered homemaker tasks and cannot be authorized as a personal care tasks.
  3. For Personal Care unit rate, Community Integration, Social Appropriateness, and Transportation are tasks which cannot be authorized under the SPED personal care service.
  4. Live-in personal care services are limited to those tasks identified on the SFN 1012, Monthly Rate Worksheet.

 

 

 

 

 

 

 

 

 

 

 

 

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